Case Summary: In less than 400 words, please summarize the case. Briefly describe the case and any particular complexities and/or complications encountered.: This is a 38-year-old female with no past medical history who presented with acute onset left facial droop, dysarthria, left hemiparesis and hemisensory deficit. She was confirmed to have a right middle cerebral artery occlusion at the M1 segment and received intravenous tenecteplase 89 minutes after symptom onset at an outside hospital. CT angiogram showed a 2mm shelf-like projection of the right internal carotid artery, consistent with carotid web. Transfer was initiated for mechanical thrombectomy and upon arrival at accepting institution, NIHSS had increased for worsening left sided weakness. She underwent thrombectomy with TICI 3 reperfusion achieved in one pass. Early neurologic improvement was noted with a 24 hour NIHSS of 2 for left pronator drift and mild left hemisensory deficit. She was started on aspirin 81mg daily for secondary stroke prevention. She underwent comprehensive search for thromboembolic sources including transesophageal echocardiogram, telemetry monitoring, thrombophilia labs (anti-cardiolipin antibodies, lupus anticoagulant, beta-2 glycoprotein, factor V leiden, anti-thrombin III, protein C and S), and CT chest/abdomen/pelvis for malignancy screening. Of these, the only significant finding was a patent foramen ovale (RoPE score 8). Transcranial doppler with microembolic monitoring was also pursued, which revealed frequent micro-emboli signals isolated to the right middle cerebral atery waveforms. Given the TCD results, medical therapy was escalated to dual antiplatelet therapy with aspirin 81mg and clopidogrel 75mg daily, with subsequent therapeutic aspirin resistance and P2Y12 levels (385 and 8, respectively). Despite adequate medical treatment, she developed a recurrent right MCA occlusion 2 days after initial presentation, requiring repeat thrombectomy. Post procedure, she was continued on aspirin and ticagrelor at which time a repeat TCD was obtained and showed a total of 16 micro-emboli in the right anterior circulation. Though patient’s TEE did reveal PFO, the absence of DVTs as well as continued isolated micro-emboli to the right anterior circulation despite maximum medical therapy made the carotid web a more likely source of her recurrent strokes. Decision was therefore made to pursue right internal carotid stenting, which she underwent 6 days post-MT. TCD was again performed 3 days post-stenting, revealing complete absence of micro-emboli and patient has not had any further neurologic events.