This middle aged patient was admitted with history of sudden onset weakness of the left hand about 8-10 days ago. There was past history of transient numbness of left upper limb lasting for 1-2mins about one month ago. MRI brain revealed multiple acute right fronto-parietal infarcts the arranged as a ‘string of pearls’.

DWI images on day of stroke showing multiple acute infarcts in right frontal and parietal region involving both the cortex as well as the subcortical white matter and centrum semiovale

MRA revealed ~ 70% stenosis of proximal RICA.

CE-MRA MIP image showing signal loss and stenosis at right carotid bulb (hand-marked arrow); remaining neck vessels are normal

Carotid DSA was planned with the aim for revascularization.

Right common carotid artery injection revealed a plaque with filling defect in the RICA just beyond the bifurcation with a meniscus sign (suggestive of fresh intraluminal thrombus), causing a 70% stenosis.

RCCA injection lateral view showing the thrombus and stenosis of the carotid bulb

As there was a fresh intraluminal thrombus, revascularization was deferred in view of a high risk of distal embolization. The patient was kept on medications  (heparin for a week, clopidogrel, aspirin, atorvastatin)for a period of 2 weeks.

She had gradual and continuous improvement in power and came for DSA after a month.

DSA this time showed resolution of the thrombus and now only a mild smooth stenosis remained.

Follow up DSA after a month showing mild stenosis with no evidence of thrombus

She has been doing well till now and had near complete recovery of power with no further ischemic neurological events