Awoman in her early 60swith a history of hypertension and hyperlipidemiawas transferred toourhospital aftermultiple transient ischemicattacksand left internal carotidartery (ICA) stenosisduring thepast severalmonths.Hermost recentpresentationwas 1weekprior foraminor strokewith amaurosis fugax, slurred speech, rightsided weakness, and facial droop lasting longer than 24 hours. Magnetic resonance imaging of the brain demonstrated subacute infarctions involving the left frontal and parietal hemispheres. She was a current smokerandwas takingaspirinandstatinmedicationat the time of presentation. Workup at another facility prior to transfer included computedtomographicangiographyof theneck,whichshowedchronic occlusion of the right ICA and 95% stenosis of the left ICA. On examination, the patient was afebrile with a heart rate of 69 beats/min andbloodpressureof 134/69mmHg.Pertinent findings includedno carotid bruit, a regular cardiac rhythm, andequally palpable upper extremity pulses bilaterally. The patient was neurologically intact, save for 4/5 motor strength in her right upper extremity. Computed tomographic angiography of the head andneckwas performed (Figure 1). Quiz at jamasurgery.com A B