Fig. 2.

Case 13, a 75-year-old man. He was initially treated with IVT alone 27 min after arrival (135 min from onset). a Initial DWI shows no acute infarct. b MRA shows ICAO with a patent ICT and MCA. The signal from the ipsilateral MCA is weak but visible (white arrow). MT was withheld because of mild symptoms (NIHSS score 5) and patent ICT. At 300 min after IVT, he presented with global aphasia, conjugate deviation, and right hemiplegia (NIHSS score 22). c Emergent DSA shows left tandem ICAO (ICA and proximal M1 MCA segment) (white arrowheads). He was immediately treated with MT with a stent retriever, obtaining complete recanalization. d After MT, infarcts on the upper MCA territory are confirmed. Symptoms gradually improved, but clinical outcome at discharge was unfavorable because of aspiration pneumonia. IVT, intravenous thrombolysis; DWI, diffusion-weighted imaging; MRA, magnetic resonance angiography; ICAO, internal carotid artery occlusion; ICT, internal carotid artery terminus; MCA, middle cerebral artery; MT, mechanical thrombectomy; NIHSS, National Institutes of Health Stroke Scale; ICA, internal carotid artery; DSA, digital subtraction angiography.