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Introduction/Purpose Retained surgical materials are an uncommon but recognized cause of postoperative complications, typically presenting with localized inflammatory or infectious sequelae. Distant embolization of retained suture material to the intracranial vasculature has not been previously described. We report a rare case of acute ischemic stroke symptoms caused by intracranial embolization of a retained cardiac suture fragment and highlight the diagnostic and therapeutic role of digital subtraction angiography (DSA) and mechanical thrombectomy.Materials and Methods We describe a 67-year-old female with a history of rheumatic heart disease status post prior mitral valve repair and recent redo mitral valve surgery, as well as atrial fibrillation on anticoagulation, who developed acute expressive aphasia postoperatively. A stroke code was activated. Neurological examination revealed a National Institutes of Health Stroke Scale (NIHSS) score of 5. Non-contrast head computed tomography was unremarkable. Computed tomography angiography demonstrated focal irregularity of the left middle cerebral artery (MCA) M2 branch concerning for sub-occlusive thrombus. The patient underwent diagnostic DSA, which confirmed persistent sub-occlusive material. Mechanical thrombectomy was performed using aspiration catheters with multiple passes.Results Successful reperfusion was achieved with thrombolysis in cerebral infarction (TICI) grade 3 after a fourth aspiration pass. The retrieved material was grossly and histologically identified as a knotted suture fragment. Surgical review determined that the material was not from the recent surgery, suggesting embolization of retained suture from prior cardiac surgery performed 27 years earlier. Post-procedure, the patient demonstrated rapid neurological improvement, with near-complete resolution of aphasia by the following day and complete recovery at one-week follow-up.Conclusion This case represents, to our knowledge, the first reported intracranial embolization of a retained suture fragment presenting with acute ischemic stroke symptoms. It underscores the importance of considering atypical and non-thrombotic embolic sources in patients with prior cardiac surgery, even decades later. Furthermore, it highlights the critical role of diagnostic DSA in identifying unusual embolic material and guiding management decisions. Mechanical thrombectomy can be an effective and safe treatment in selected cases of medium-vessel occlusion caused by non-thrombotic emboli, resulting in excellent clinical outcomes.Left: Digital subtraction angiography showing flow-limiting sub-occlusive material in the left M2 inferior segment of the middle cerebral artery. Right: Photograph of a fragment of knotted suture retrieved with thrombectomy. Confirmed with formal gross pathological evaluation.Disclosures M. Bedoya Sommerkamp: None. M. Mishra: None. I. Migdady: None. M. Nahhas: None. S. Sheth: None. R. Regenhardt: None.Abstract E-215 Figure 1