The patient came to the clinic 20-October-2012 complaining of sudden onset fainting during driving with right sided paresis occurred 3 hours ago.

On examination: the patient is walking talking with headache in the left side. There is weak distal muscles both left limbs 4/5.

The patient was sent for MRI of the brain with contrast with MRA of the brain and carotids, which revealed complete stenosis of the left ICA at the bifurcation and thrombotic phenomena of the artery and its branches with scattered mild white infarctions in the brain parts supplied by this artery.

The patient was admitted to the ICU and heparinization of low dose was started. CT-scan was done immediately before surgery.

Using Inomed Neuroexplorer carotid artery protocol, exposure of the left CCA, ICA and ECA. There is no superior thyroid artery in the field. The vagus nerve, IJV and hypoglossal nerve were identified. Clamping of all major arteries. The carotid bulb was felt stony hard, over what longitudinal incision was done with insertion of Javid shunt. and heamostasis was secured. All the athermanous plaque which was totally occluding the ICA was removed and meticulous cleaning of all debris was achieved. Carotid graft was used and the vascular wall was repaired with the carotid graft. The Javid shunt was removed and a clamp was kept in the ICA. After strict heamostasis and allowing to flow first to the ECA, the clamp was released from the ICA. A small piece of surgicele was left over the graft.

Routine closure of the wound. Smooth postoperative recovery with slight deterioration of the power of the right extremities and the face.

The patient sent for CT-scan and it was the same as the one before the surgery. The patient gradually start to improve neurologically after the surgery.

The patient had total occlusion of the left ICA. To avoid catastrophic deterioration, heparinization and endarterioectomy are the best options.