Introduction: Neurological symptoms, such as facial asymmetry, speech abnormalities and weakness, are common presentation to the Emergency Department, with acute stroke being the most important differential that must be diagnosed in timely manner for appropriate management. Such symptoms are typical presentations of anterior circulation strokes. Posterior circulations strokes can be more complicated to diagnose, clinically and radiographically, as more vague symptoms such dizziness, vomiting or visual disturbance usually prevail. Less common atypical symptoms can be missed and failed to be identified as stroke. Anterior circulation strokes are more common, with MCA being the culprit in most cases. ACA occlusions with resultant ischemic stroke is less prevalent. When present, the main symptom is weakness in the lower limb with mildly deranged upper limb weakness. Case description: 42 years old Indian man, known case of uncontrolled type 2 DM and Hypertension, presented to the ER, with 14 hours of worsening right lower limb numbness with decrease sensation. Patient been having gradually symptoms for 2 days prior to the sudden decline in sensation. Patient denied any other neurological symptoms. He had history of acute ischemic stroke (Acute left lateral medullary infarct) 8 months prior to his presentation. Examination revealed decreased sensation in right lower limbs, with positive SLR. Patient has full motor power in all 4 limbs, no cranial nerves deficit and no cerebellar signs. CT angiography showed left ACA – A2 complete occlusion with a mismatch present in CT perfusion study. Patient underwent mechanical thrombectomy immediately. Patient had complete resolution of symptoms and was discharged 2 days later from hospital. Discussion: Code strokes are common in tertiary hospital and aim to expediate imaging and fasten the response of the multidisciplinary team managing strokes. BE-FAST is a quick tool used in pre-hospital setting and hospital settings for early stroke recognition. Such tools omit less common symptoms of stroke, that are usually caught when patients are high risk of stroke, despite the symptoms or clinical examination. Recurrent strokes should be suspected in any patient presenting with any new or worsening focal neurological deficit.

Keywords: ACA occlusion, stroke, sensory deficit, symptom mismatch.