A 58 year-old man woke up with numbness and clumsiness of his right hand. Additionally, he complained of difficulty thinking and often felt like she would fall. On neurological examination he had full strength, but in comparative testing the right hand was weaker. His past medical history was remarkable for arterial hypertension and coronary heart disease with coronary stenting undertaken 12 years ago. The patient was diagnosed with a proximal left internal carotid artery stenosis (CT angiogram). In addition, brain imaging showed subcortical and cortical ischemic changes and increased Tmax on head CT perfusion imaging (Figures 1) further supporting the diagnosis of a symptomatic carotid artery stenosis.
Figure 1: Ischemic cerebral changes are seen in centrum semiovale and left parietal cortex (top row: brain MRI/FLAIR). Cerebral perfusion imaging with increased Tmax in the left hemisphere (CT perfusion; bottom).
The patient was placed on ASA, statin, and antihypertensive medication. On baseline conventional angiogram, there was reduced visualization of intracranial arteries due to a high-grade left internal carotid artery stenosis. Carotid angioplasty and stenting was performed to restore intracranial circulation with excellent radiological and clinical outcome (Figures 2).  
Figure 2: 58 year-old man with symptomatic high-grade stenosis of the proximal left internal carotid artery (ICA) (filling defect market as yellow,* top middle). Pre-operative, reduced filling of the left middle cerebral artery (M) and no filling of the anterior cerebral artery (A) (top left). External carotid artery branches, superficial temporal and middle meningeal arteries filling ahead of the intracranial circulation on cerebral angiogram (left). Carotid angioplasty and stenting (center) with restitution of carotid lumen post-op (bottom middle) and restoration of intracranial flow with visualization of branches of middle and anterior cerebral arteries (right). 
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