Calcified embolus mimics patent middle cerebral artery on CT angiogram

A 61-year-old woman presented with acute symptoms of right middle cerebral artery ischaemia, with left face/arm/leg weakness, right gaze preference and homonymous hemianopia. A non-contrast CT scan of the head showed a calcified Y-shaped hyperdensity at the right middle cerebral artery bifurcation (figure 1A). We did not identify any contraindications for thrombolytic therapy, and the patient was treated with intravenous tissue plasminogen activator. Figure 1 Hyperdense calcific thrombus at the right middle cerebral artery bifurcation. We used a multi-phase CT angiogram to assess her cerebrovascular status. We expected a role for endovascular intervention given the clinical deficits and corresponding right middle cerebral artery bifurcation hyperdensity, which we assumed to be thrombus. However, the initial phase of the CT angiogram did not show the expected occlusion …