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A 71-year-old African-American male presented 3 hours post-onset of a dense left hemiparesis with a clinical syndrome consistent with severe right hemispheric ischemia. Urgent computed tomography of the brain was negative, so the patient was brought to the interventional suite for intra-arterial (IA) thrombolysis. An angiogram of the right common carotid artery (CCA) ([a] anteroposterior [AP] view; [b] lateral view) showed occlusion of the middle cerebral artery (MCA) trunk (white arrow in a and b) with no pial collateral flow: note the absence of MCA distal cortical branches (black arrowheads in a and b). The internal carotid artery (ICA) had severe tortuosity with an extra loop in the distal cervical segment (black arrow in a and b), as well as excessive tortuosity and diffuse atherosclerosis of the intracranial segments (white arrowheads in a and b). The anterior cerebral artery filled normally (curved arrow in a and b) and there was a large posterior communicating artery filling the posterior cerebral artery. Due to the severe tortuosity, a long 8-Fr sheath was placed in the distal CCA and a 6-Fr guide catheter was placed distally in the cervical ICA (black arrow in c; slight ipsilateral oblique view). The microcatheter was then guided over a 0.014-inch, hydrophilic, soft-tipped guidewire into the occluded segment of the MCA (white arrow in c). The patient then received 25 mg of IA tissue plasminogen activator over 20 minutes with only minimal improvement in flow. At that point, the microcatheter was exchanged for a 1.5 × 9 mm coronary balloon, which was used to perform percutaneous transluminal angioplasty of the occluded segment of the MCA (white arrow in d; slight ipsilateral oblique view). Note that the balloon has a "waist", which suggests that an underlying stenosis is the cause of the occlusion. Also note the distal placement of the microwire (black arrow in d) to give support for balloon advancement. Following angioplasty, there was transient TIMI 2 flow in the MCA, but by the time repeat angiography was performed the MCA had reoccluded (black arrow in e; slight ipsilateral oblique view). This is typical of an active atherosclerotic lesion. Angioplasty was repeated and then followed by 6 mg of abciximab infused over 5 minutes directly through the microcatheter into the stenotic segment. Fifteen minutes later, an AP angiogram (f) showed complete recanalization of the MCA trunk, but with an underlying residual stenosis (white arrow). Re-established flow could be seen in the distal MCA branches (black arrows in f). The lateral angiogram (g) showed filling of most of the MCA branches (white arrows), but there was persistent thrombus in one of the frontal branches (black arrow). The procedure was terminated, but the patient received aspirin and clopidogrel orally immediately at the end of the procedure. By the second postoperative day he was nearly normal, except for slight hemineglect. Magnetic resonance imaging of the brain (h) showed only a small insular cortex stroke (arrow); by 30 days, the patient was neurologically normal.