Anterior cerebral artery (ACA) strokes are rare and often present atypically. We report a case with an isolated left distal A2 segment ACA occlusion presenting with global aphasia and dense right hemiparesis, features typical of a left middle cerebral artery (MCA) syndrome, and representing a severely disabling neurological deficit. CT perfusion imaging confirmed a viable mismatch correlating with the occlusion. The patient underwent a successful thrombectomy with immediate marked neurological improvement and with complete neurological recovery by discharge. While data remain limited, this case illustrates the complex and evolving decision-making process surrounding thrombectomy for distal ACA occlusions with disabling deficits, particularly when perfusion imaging reveals only a 5 cc infarct core and 8 cc of potentially salvageable penumbra, and when recent trial data question population-level benefit. This case highlights the importance of integrating clinical severity with perfusion-based imaging in selecting patients who may still benefit from endovascular intervention despite distal vessel location. Early recognition and intervention in such atypical cases can lead to excellent outcomes.
Ezzeldin et al. (Mon,) studied this question.