A 65-year-old man presented with right arm and face weakness associated with severe coughing fits. A computed tomography angiogram revealed an occlusion of the left common and internal carotid arteries and an incomplete circle of Willis. An arch angiogram demonstrated reconstitution of the left external carotid artery, which collateralized with the intracranial left internal carotid artery. The patient underwent left subclavian-to-external carotid artery bypass with reversed saphenous vein, with complete resolution of symptoms over 1 year of follow-up. Cough-induced hemispheric transient ischemic attack is a rarely described hemodynamic phenomenon that can be managed with revascularization of the external carotid artery in select patients.