Objective The gold standard for the diagnosis of intracranial atherosclerosis remains catheter based digital subtraction angiography (DSA). A symptomatic hemodynamically non-significant intracranial atherosclerotic lesion is described, whose underlying embologenic characteristics were not detectable by either DSA or three-dimensional rotational angiography (3DRA) but fully realized by C-arm cone beam CT (CBCT) angiography.

Clinical presentation A 73-year-old man presented with crescendo transient ischemic attacks consisting of right arm tingling and hand weakness despite long term dual antiplatelet therapy with aspirin and clopidogrel for coronary artery stent. DSA and 3DRA demonstrated a smooth benign appearing left cavernous internal carotid stenosis of <50%.

Intervention Given the incongruence of the lesion with the patient's symptoms and lack of response to aggressive medical treatment, a decision was made to obtain higher resolution imaging. CBCT angiography was obtained with injection at two contrast dilutions, which uncovered an underlying ruptured ulcerated calcific plaque with a small dissective component and overlying thrombus. The lesion was treated with anticoagulation followed by balloon mounted stent angioplasty, with symptom resolution and maintained patency at the 1 year follow-up.

Conclusion The superior spatial resolution and dynamic range characteristics of CBCT angiography provide added clinical utility in disambiguation of questionable intracranial atherosclerotic lesions which may be missed by conventional planar and rotational angiography. The additional information provided by CBCT angiography could be useful in lesion risk stratification and help refine indications for intracranial stent angioplasty given its recent documented shortcomings vis a vis medical management.