Single-vessel occlusions often cause an acute ischemic stroke (AIS) but can rarely be caused by multi-vessel occlusions. Although bilateral AIS is rare, these patients often undergo mechanical thrombectomy as long as they are within the 24-hour window since symptom presentation. We present a case of a female in her 70s who presented to an outside facility with right-sided weakness in her upper and lower extremities, drooping of the right lower face, and aphasia. The patient developed bilateral symptoms on transfer to a tertiary center with neuro-interventional capabilities. Due to concern for a possible bilateral stroke, magnetic resonance imaging was ordered and was remarkable for bilateral middle cerebral artery occlusion. The patient underwent a successful bilateral mechanical thrombectomy within 24 hours of the last known normal. This case demonstrates that mechanical thrombectomy is an excellent treatment option for patients with bilateral occlusions that present within the recommended 24 hours from the last known normal.

A persistent primitive hypoglossal artery (PPHA) is an anatomical variant resulting in persistent carotid-vertebrobasilar anastomoses. This variant arises from the distal cervical segment of the internal carotid artery (ICA) between C1 and C3 and passes through an enlarged hypoglossal canal to join the basilar circulation. This case report describes a 60-year-old male with an acute ischemic event secondary to an occlusion in the right ICA and PPHA, resulting in a unique physical examination. Digital subtraction angiography (DSA) was utilized to visualize occlusion of the right common carotid artery with no residual right internal carotid artery or right vertebral artery filling. The patient\'s presenting symptoms yielded a unique neurological examination, making it difficult to localize a solitary lesion, which would account for the patient\'s acute presentation. In retrospect, with angiography revealing a right PPHA, his presentation fit more thoroughly with the clinical picture. With the increased utility of neuro-endovascular procedures, clinicians have a higher probability of encountering diverse angiographical findings. With this case report, we would like to familiarize practitioners with the presence of PPHA, present unique imaging findings involving typically isolated vascular territories, and stress the importance of clinical judgment when making decisions regarding stroke care.

Metastases to the brain from primary colorectal carcinoma are rare. Existing literature describing cranial nerve palsy from metastatic colorectal cancer is scattered. To our knowledge, we are the first to describe the combination of CN deficits V, VII, and XII as the initial presentation of colorectal malignancy. The authors present the case of a patient with no past medical history who presented with multiple cranial nerve deficits of the right trigeminal, facial, and hypoglossal nerves. MRI of the brain revealed a mass in Meckel\'s cave, which explained the involvement of the trigeminal nerve (CN V) but not the facial (CN VII) and hypoglossal (CN XII) nerves. Further workup revealed multiple cardioembolic strokes caused by nonbacterial thrombotic endocarditis (NBTE). Extensive workup for the cause of his NBTE and subsequent cerebrovascular events revealed colorectal adenocarcinoma.