Smoker’s disease, also known as anomalous vascular network at the base of the brain, is a group of cerebrovascular diseases characterized by narrowing or occlusion of the siphon of the internal carotid artery and the beginning of the anterior and middle cerebral arteries, and the appearance of anomalous small vascular network at the base of the brain. The disease is called smoker’s disease because the cerebral angiogram shows many dense piles of small vessels, resembling the smoke exhaled during smoking. The disease was first described by Shimizu and Takeuchi in Japan in 1955 and named by Suzuki in 1966. It has been found in Chinese and Japanese as well as in Caucasians, Negroids, and Caucasians. According to the literature, the Chinese and Japanese are the most common. Smoky disease – etiology It should be noted that smoky disease is not related to smoking. Some scholars have found that mother and son or brother and sister in individual families can have similar disease, which is considered to be related to congenital factors. However, based on clinical, pathological, immunological and laboratory studies, most scholars believe that this is a group of occlusive cerebrovascular diseases that occur later in life and may be related to allergic cerebral vasculitis. Smoky disease – symptoms and signs Smoky disease is more common in children and adolescents, and often starts as a stroke, which can manifest as cerebral thrombosis or cerebral hemorrhage and subarachnoid hemorrhage. Patients may present with varying degrees of hemiparesis or sequential paralysis on the right and left sides, which may be accompanied by aphasia, choking, dysphagia, mental retardation, dementia, seizures, headaches, and transient ischemic attacks. Infarcts or hemorrhagic changes are usually seen on CT scans of the head. Infarcts are often multiple, with frontal, temporal, parietal, occipital, basal ganglia regions, and thalamus being the most common, and frontal lobe atrophy may be combined in half of the patients. The hemorrhages can be lobar hemorrhages, basal ganglia hemorrhages, or subarachnoid hemorrhages, and most of the cerebral hemorrhages caused by hypertension are located in the basal ganglia region. Patients with cerebral hemorrhage may also have concurrent findings of infarct foci and/or cerebral atrophy. Cerebral angiography may reveal stenosis or non-visualization of the beginning of the internal carotid artery, the beginning of the anterior and middle cerebral arteries, and a large number of tiny vascular clusters in the basal ganglia region like smoke exhaled from a cigarette. In addition, a compensatory branch of the collateral circulation can be formed in the brain. As the disease progresses, the number of compensatory anastomosing branches gradually decreases or shrinks. Smoky disease – treatment Smoky disease has no ideal treatment because the cause of smoky disease is unknown. The medical treatment is symptomatic with vasodilators and antibacterial agents, but the efficacy is not satisfactory. Surgical treatment is mainly surgical, and the core of all of them is to divert the external carotid artery into the skull. The former is more difficult because of the thin diameter of the middle cerebral artery in smog patients, especially in children, and the need to temporarily block the middle cerebral artery during surgery may further aggravate cerebral ischemia. Therefore, most scholars use the EDAS indirect anastomosis method invented by Japanese scholar Mr. Yoshiharu Matsushima in 1979, in which the extracranial vessels are led across the skull and dural barrier to the intracranial area to promote the blood supply to the cerebral cortex. In this type of patients, we can perform multi-point drilling of the skull to allow extracranial blood supply to participate in the intracranial area and improve the patient’s symptoms after appropriate examination to determine the site of ischemia.