Introduction The CT angiogram is an essential tool to plan catheter access to the cerebral circulation in stroke patients. However, in cases that appear very challenging, angiography is necessary.

Clinical case We present a 79-year-old male, who had severe atherosclerosis and had undergone revascularization surgery, including carotid-carotid bypass and left subclavian-carotid bypass.

He presented to the emergency department with acute gait disturbance. CT scan revealed a left temporo-mesial hypodensity. The CTA showed a basilar artery occlusion and a left common carotid artery as the only trunk emerging from the aortic arch. There was a left V1 segment occlusion and the right V4 segment was hypoplastic, apparently leaving no access to the basilar artery.

The MRI confirmed a lesion at the left temporal lobe, and showing small foci of recent ischemia in bilateral occipital lobes.

In the following hours, the patient worsened clinically so we decided to perform endovascular treatment.

We used a right brachial artery access and crossed the right hypoplastic V4 to perform the thrombectomy with a stentriever (Tiger ®), achieving a TICI 2b recanalization.

The control CT showed no new lesions and the patient had a favorable clinical outcome.

Conclusion CT angiography showed an apparent lack of access to reach the basilar artery. Nevertheless, the active search for unconventional roads led us to take advantage of an, a priori, non-navigable vessel, with successful recanalization. This underlines that patients should not be refused endovascular treatment based on the apparent lack of access to the cerebral circulation.

Disclosure of Interest Nothing to disclose