case_images: PMC10719034_01
case_images: Noncontrast axial CT head demonstrates a rounded calcification (arrow) within the right carotid terminus.
case_images: CRIRA2023-1653631.001.jpg
case_images: PMC10719034_01_CRIRA2023-1653631.001.jpg
case_images: fig1
case_images: Noncontrast CT of the head was obtained demonstrating a rounded calcification at the right carotid terminus (Figure 1).
case_images: CT angiography of the head. Coronal maximum intensity projection (MIP) demonstrates occlusion of the right carotid terminus (arrow) due to calcified cerebral embolus and absent flow within the right M1 middle cerebral artery (arrowheads).
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case_images: fig2
case_images: CT angiography and CT perfusion were performed demonstrating a 5 mm rounded, calcific density within the supraclinoid right internal carotid artery (ICA) (Figure 2) and occlusion of the proximal right M1 MCA with narrowing at the MCA trifurcation and a large right MCA perfusion deficit and penumbra (Figure 3). Catheter-based cerebral angiography was performed approximately 30 hours following the initial presentation, demonstrating complete occlusion of the right internal carotid artery terminus and right M1 MCA (Figures 4(a) and 4(b)).
case_images: (a-d) CTA perfusion was obtained approximately 14 hours following presentation, following delivery by cesarean section. Perfusion maps demonstrate reduced blood flow (a) and reduced mean transit time (b) in the right MCA territory. Initial MRI (c) obtained within 3 hours following presentation demonstrates a focus of diffusion restriction in the right basal ganglia and corona radiata, measuring up to 4 cm compatible with core ischemic infarct. Postprocedure MRI (d), obtained after attempted thrombectomy and surgical endarterectomy, approximately 48 hours from the prior MRI, demonstrates stable 4 cm core infarct with sparing of the majority of the at-risk territory.
case_images: CRIRA2023-1653631.003.jpg
case_images: PMC10719034_01_CRIRA2023-1653631.003.jpg
case_images: fig3
case_images: CT angiography and CT perfusion were performed demonstrating a 5 mm rounded, calcific density within the supraclinoid right internal carotid artery (ICA) (Figure 2) and occlusion of the proximal right M1 MCA with narrowing at the MCA trifurcation and a large right MCA perfusion deficit and penumbra (Figure 3). Catheter-based cerebral angiography was performed approximately 30 hours following the initial presentation, demonstrating complete occlusion of the right internal carotid artery terminus and right M1 MCA (Figures 4(a) and 4(b)). Her follow-up MRI the day following surgical embolectomy, approximately 2 days after her initial presentation, showed approximately stable size of the core infarct with sparing of the majority of at-risk right MCA territory (Figure 3).
case_images: (a-d) Digital subtraction angiography, arterial phase, and frontal and lateral views, obtained during injection of the right internal carotid artery (a, b) pre- and post-endarterectomy and embolectomy (c, d), demonstrate complete occlusion of the right internal carotid artery at the terminus (a, b), with complete recanalization (TICI 3) following endarterectomy and embolectomy (c, d). There is metallic subtraction artifact due to aneurysm clip overlying the carotid terminus on frontal view (c).
case_images: CRIRA2023-1653631.004.jpg
case_images: PMC10719034_01_CRIRA2023-1653631.004.jpg
case_images: fig4
case_images: CT angiography and CT perfusion were performed demonstrating a 5 mm rounded, calcific density within the supraclinoid right internal carotid artery (ICA) (Figure 2) and occlusion of the proximal right M1 MCA with narrowing at the MCA trifurcation and a large right MCA perfusion deficit and penumbra (Figure 3). Catheter-based cerebral angiography was performed approximately 30 hours following the initial presentation, demonstrating complete occlusion of the right internal carotid artery terminus and right M1 MCA (Figures 4(a) and 4(b)). A rounded calcified embolus was removed (Figure 5), and there were no immediate surgical complications, with postoperative angiography demonstrating complete recanalization TICI 3 (Figures 4(c) and 4(d)).
case_images: (a) Intraoperative view of the calcified embolus in the carotid terminus. (b) Gross specimen of the calcified embolus removed at surgery.
case_images: CRIRA2023-1653631.005.jpg
case_images: PMC10719034_01_CRIRA2023-1653631.005.jpg
case_images: fig5
case_images: A rounded calcified embolus was removed (Figure 5), and there were no immediate surgical complications, with postoperative angiography demonstrating complete recanalization TICI 3 (Figures 4(c) and 4(d)).
case_images: Contrast-enhanced CT of the abdomen and pelvis, coronal view, demonstrates calcified phleboliths in the left pelvis (arrow) measuring up to 5 mm, similar in size and morphology to the calcified cerebral embolus.
case_images: CRIRA2023-1653631.006.jpg
case_images: PMC10719034_01_CRIRA2023-1653631.006.jpg
case_images: fig6
case_images: Additional investigations revealed a patent foramen ovale and calcified phleboliths in the pelvis (Figure 6); no calcified arterial plaque or other potential source of calcified emboli was identified.