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A 47-year old man was last seen well at 21:30h. At 03:30h he was noted to have global aphasia and moderate right-sided weakness. He was evaluated at a comprehensive stroke center at 06:35h. His NIHSS score was 15.

The CT scan showed early infarct signs in the left middle cerebral artery (MCA) territory; ASPECT score was 5, with sparing of the deep structures (lentiform nucleus, caudate and internal capsule). CT angiography revealed an occlusion of the mid M1 segment of the left MCA.

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A CT perfusion scan revealed a large cortical lesion with severe reduction in CBF (103 ml) on the RAPID map. The Tmax > 6s lesion was 147 ml (44 ml of mismatch).

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An occlusion of the left MCA was found on angiography (top left and center panels). Endovascular therapy was performed and TICI 2b reperfusion was achieved (bottom left and center panels).

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A follow-up MRI scan at 24 hours revealed a DWI lesion of approximately 100 ml that matched the size and location of the baseline CT Perfusion core lesion. The patient was discharged 8 days after admission with an NIHSS of 8 and a modified Rankin score of 3.