Distal Left Anterior Cerebral Artery (ACA) Occlusion Masquerading As Middle Cerebral Artery (MCA) Syndrome: To Treat or Not to Treat?

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.