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A 63-year-old male patient, with no prior medical control, smoker, and  alcohol consumer, presented to the emergency department after a fall, resulting in head trauma and left hemiparesis of 11 hours duration. There were no language, sensory, visual disturbances, or loss of consciousness.

Upon examination, muscle strength of 3/5 in the left upper limb and 2/5 in the left lower limb. No other neurological deficits were noted. NIHSS score was 5.

A non-contrast brain CT scan revealed a right parietal hypodense lesion consistent with a right partial anterior circulation infarct (PACI - Oxfordshire classification).

Etiologic studies included echocardiography and neck doppler ultrasound. Echocardiography showed moderate concentric left ventricular hypertrophy, mild left atrial dilation, and preserved ejection fraction. Doppler ultrasound revealed left carotid atheromatous disease without significant stenosis, and notably, the right internal carotid artery was not visualized.

A supra-aortic CT angiography documented hypoplasia of the right common carotid artery and agenesis of the right internal carotid artery (type A according to the Lie and  Quint classification). In the intracranial circulation, the left middle cerebral artery arised from the posterior communicating artery, while the left anterior cerebral artery arised from the anterior communicating artery.

The patient was managed according to the standard acute stroke protocol and additional diagnoses of arterial hypertension, diabetes mellitus II, and dyslipidemia were established and appropriately managed.