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A 54 year-old with hypertension and a 2-day history of unsteady gait presented with sudden onset right-sided paralysis, difficulty speaking and left gaze preference. He was treated with i.v. tPA at a local hospital and transferred to an endovascular center where his NIHSS score was 22. The CT ASPECT score was 10 and the CT angiography showed bilateral, proximal, internal carotid artery (ICA) occlusions. The RAPID mismatch map is shown above.

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RAPID revealed severe perfusion delay in both hemispheres but cerebral blood volume (CBV) and cerebral blood flow (CBF) was generally well preserved. Note that RAPID selected the arterial input function (AIF) from the basilar artery because of the bilateral carotid flow disturbance.

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The patient underwent successful angioplasty and stenting of the left internal carotid artery (ICA). No thrombus was present in the left middle cerebral artery (MCA). Good flow was established to the right anterior cerebral artery (ACA) and MCA territories via the anterior communicating artery (bottom right panel). The left ICA was treated first because the left hemisphere was symptomatic. No intervention was performed on the occluded right carotid.

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Follow-up MRI revealed small, punctate DWI lesions in bilateral watershed distributions. The patient had a dramatic clinical recovery with an NIHSS of zero by 48 hours.