Rare culprit and clinical dilemma: thrombolysis in a spontaneous anterior cerebral artery dissection

Intracranial arterial dissection (IAD) is a rare cause of ischaemic stroke, with involvement of the anterior cerebral artery (ACA) being uncommon. We present the case of a woman in her mid-40s who developed acute right leg weakness associated with a headache. Initial non-contrast CT (NCCT) and CT angiography (CTA) scans were reported as normal; she was thrombolysed with intravenous alteplase for a clinical diagnosis of stroke. Post-thrombolysis NCCT showed an infarct in the left ACA territory. At the time of review, in our weekly neuroradiology meeting, a dissection of the proximal left ACA was identified. This case highlights a critical diagnostic challenge, demonstrating that IAD can be elusive on initial imaging interpretation. The patient's successful outcome following thrombolysis and antiplatelet therapy reinforces guideline recommendations that thrombolysis should not be withheld due to a suspected dissection. It underscores the vital role of multidisciplinary review in diagnosing rare stroke aetiologies and guiding effective management.