Background Calcified cerebral emboli (CCE) are a rare cause of acute ischemic stroke, with an estimated incidence of 0.3‐0.8%. They usually arise from calcified cardiac valves or atherosclerotic plaques but may also occur iatrogenically after vascular procedures. On non‐contrast CT (NCCT), CCE appear as hyperdense lesions that may mimic hemorrhage or vascular wall calcification, often delaying diagnosis. Standard reperfusion is limited because thrombolysis is ineffective and thrombectomy often fails due to the embolus's rigidity and irregular morphology. Case Presentation An 81‐year‐old man with atrial fibrillation on apixaban, peripheral artery disease, hypertension, and COPD presented with fluctuating right‐sided weakness and facial droop. Ten days earlier, anticoagulation had been held for an abdominal aorta angiogram, after which he developed transient right arm deficits and was found to have multiple embolic infarcts. He returned with worsening symptoms. NCCT Figure 1A, 1B and CT angiography Figure 1C revealed a 4‐mm hyperdense lesion in the left M1 segment causing critical stenosis, consistent with a calcified embolus. CT perfusion showed a large ischemic penumbra Figure 1D. Treatment and Outcome He was ineligible for thrombolysis and initially not offered thrombectomy due to preserved distal flow. Angiography confirmed severe M1 stenosis, and mechanical thrombectomy was attempted and initially successful. Hours later, he deteriorated to dense left MCA syndrome (NIHSS 15). Repeat angiography showed left ICA terminus occlusion. Emergency balloon‐mounted stenting achieved successful reperfusion Figure 2. Post‐procedure, right‐sided strength partially improved, though expressive aphasia and facial weakness persisted. His course was complicated by COPD exacerbation requiring intubation, after which he elected for comfort care. Conclusion CCE are rare but challenging stroke etiologies. Balloon‐mounted stenting may provide a rescue option when conventional methods fail, though risks must be weighed. Early recognition and management of the embolic source are key to improving outcomes. image image
Suppakitjanusant et al. (Sat,) studied this question.
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