Pearls & Oy-sters: Calcified Cerebral Embolus: A Smoking Gun Guiding Acute Stroke Therapy and Secondary Prevention

Although rarely found among patients with acute ischemic stroke, calcified cerebral emboli provide diagnostic information on potential stroke etiologies to guide secondary prevention.cIn the presence of a calcified cerebral embolus, all potential sources of calcific embolism should be investigated, including the aortic valve, aortic arch, and major neck vessels. Oy-sters cReperfusion therapy can be challenging in patients with acute stroke and calcified cerebral emboli.IV thrombolysis has a low chance of being successful but should not be withheld.Endovascular treatment performed with a direct aspiration first-pass technique may improve the chances of a successful outcome.A 78-year-old man presented with sudden-onset right-sided face and arm weakness and dysarthria.Upon arrival, at 60 minutes after symptoms onset, his NIH Stroke Scale (NIHSS) score was 4 (minor right facial paralysis, right arm drift, limb ataxia present in 1 limb, and mild to moderate dysarthria).His medical history was relevant for type 2 diabetes, hypertension, coronary artery bypass graft, and former smoking.Two weeks prior to the stroke, he experienced transient vertigo and disequilibrium, which were still present at the time of his admission, although with milder intensity.Medications included aspirin 81 mg/d, telmisartan 80 mg/d, amlodipine 10 mg/d, atenolol 50 mg/d, atorvastatin 10 mg/d, coenzyme Q10 100 mg/d, and metformin 2,000 mg/d.CT of the head showed a subtle hypodensity involving the posterior aspect of the left insular ribbon, an Alberta Stroke Program Early CT Score of 9, and a punctate hyperdensity (maximum density of 531 Hounsfield units) within the left Sylvian fissure, consistent with a calcified cerebral embolus (CCE) (figure ,A).There was also a recent (≤2 weeks) probable infarction involving the left pons.Head and supra-aortic vessels CT angiogram showed a 29 × 9 mm soft and calcified (443-1,261 Hounsfield units) aortic arch atherosclerotic plaque (figure ,E) and 70% right internal carotid artery stenosis, mild left internal carotid nonstenotic plaque, and occluded left middle cerebral artery (MCA) at its mid-distal M2 portion.On multiphase arterial images, there was attenuation of the left MCA proximal to a thrombus with a calcific component, delayed washout, and a multiphase CT angiography collateral score of 3. Perfusion imaging showed a large area of potentially reversible ischemia within the posterior aspect of the left MCA territory (figure S1, available from Dryad, doi.org/10.5061/dryad.sqv9s4n1j).We considered using IV tissue plasminogen activator (tPA) but in light of a probable subacute infarction involving the left pontine region (figure S2, available from Dryad, doi.org/10.5061/dryad.sqv9s4n1j) matching the persistent vertigo, we decided to omit IV.The right arm weakness

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