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By 3 months, he returned to his neuropsychological baseline in majority of cognitive domains from moderate-severe dysfunction, with concurrent MRI demonstrating resolving white matter lesions and FFA showing less evident vasculitis. The treatment response was maintained with tapering of steroids (25mg at 12 months). He was able to return to his previous occupation as a paramedic by 1 year. Conclusion SuS is a rare, immune-mediated microangiopathy in which early recognition with aggressive immunosuppression is required to achieve optimal outcome. No randomized controlled trial (RCT) exists for the management of this condition. In this report, early recognition through multidisciplinary input and aggressive immunotherapy with rituximab resulted in a favourable outcome. However, RCT evidence is needed to guide management.