Distal occlusion, use of mCTA - CT 

86 year old male presenting with acute left sided weakness and facial droop, 3 hours from onset. NIHSS >15. Known A-fib on epixaban. Independent, living in home.

2] Baseline imaging: NCCT: 09:00 am ASPECTS: Caudate, lentiform nucleus, insula, M1, M2, M3 involved; ASPECTS score: 4 mCTA: 09:02 am Target occlusion: Right cervical ICA and M1- tandem occlusions Collaterals: Fair, with good extent and delayed washout. Arch anatomy: Type II arch, moderately difficult arch CT Perfusion: 09:06 am- Large penumbra with small infarct core (CBV vs TMax)

3] Decision making: tPA- No. On Epixaban. Poor ASPECTS. EVT- Yes, Poor NIHSS ( >15). Proximal occlusion. Fair collaterals. Challenges: Advanced age, difficult arch, tandem occlusion.

4] Endovascular treatment: Groin puncture: 09:50 am (Picture to puncture time : 50 min) DSA: No cervical ICA occlusion- pseudo-tandem occlusion T-occlusion seen. 2 passes of Solitaire 4x30 mm. Final TICI- 2c Final recanalization time: 10:50 am (Picture to recan time- 110 min)

5] 24 hour follow up MRI 24 hr NIHSS ( <5) DWI- Large areas of restricted diffusion in right MCA territory. No hemorrhagic transformation.

6] 1 year follow up MRI (March 16, 2017) Moderately large area of encephalomalacia in right MCA territory, no residual neurological deficits.