A 44-year-old male, with history of tobacco chewing and hypercholesterolemia presented with sudden onset of inability to speak. MRI revealed multiple small acute infarcts in the left temporoparietal area (Fig. 95.1a). His speech improved partially in the next few days. CT angiogram revealed severe stenosis of left internal carotid artery (Fig. 95.1b). Cerebral DSA was performed. It revealed a severe sub-occlusive stenosis at the origin of the left internal carotid artery (Fig. 95.1b and blue arrow, c). A long filling defect was also seen extending from the plaque into the middle third of cervical portion of ICA (Fig. 95.1b and red arrows, c). This was suggestive of thrombus which is usually associated with plaque rupture.