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Introduction Distal posterior circulation strokes are rare and technically challenging to manage due to their small caliber, tortuous vascular anatomy, and distal locations. We present a case of multi-territory thromboembolism involving simultaneous posterior cerebral artery (PCA) and a variant common anterior inferior/posterior inferior cerebellar artery (AICA-PICA) trunk occlusion in a male patient in his 40s. This report highlights the indispensable role of rigorous clinical examination in detecting multifocal posterior circulation ischemia not evident on initial non-invasive imaging.Methods The patient presented with acute altered mental status, right hemiparesis, and a NIHSS score of 15. He received intravenous Tenecteplase. CTA demonstrated a left P2/P3 PCA occlusion and a chronic-appearing right vertebral artery occlusion. Neurological examination revealed a right-sided ataxia, and gaze-evoked nystagmus in addition to left third cranial nerve palsy, right homonymous hemianopia and hemiparesis—suggesting multifocal involvement. Selective left vertebral angiography confirmed the distal left PCA occlusion and revealed an angiographically occult right basilar branch occlusion, later identified as a common AICA-PICA trunk. Revascularization was performed using the direct aspiration first pass technique (ADAPT). A Zoom 35 aspiration catheter (Imperative Care, Campbell, CA) was advanced to the PCA thrombus, achieving TICI 2C revascularization. Subsequently, because the ataxia was unexplained by the PCA infarct, the AICA-PICA occlusion was thought to be acute and targeted using similar techniques, achieving TICI 3 revascularization.Results Post-procedure magnetic resonance imaging demonstrated minimal residual infarction. The patient exhibited marked neurological recovery, characterized by the complete resolution of his third nerve palsy, hemianopia, hemiparesis, and right-sided ataxia. He was able to ambulate unassisted, and his NIHSS score improved to 1 by his transition to inpatient rehabilitation six days post-procedure. Following one week of rehabilitation, he was discharged home with a modified Rankin Scale (mRS) score of 1. He was diagnosed with an embolic stroke of undetermined source and discharged on aspirin.Conclusions Standard stroke assessments incompletely characterize the nuanced and overlapping deficits of posterior circulation ischemia. This case underscores that a meticulous clinical examination remains paramount for accurately localizing multifocal thromboembolic events. Clinicians must rely on localizing physical signs to drive targeted angiographic exploration, particularly when initial non-invasive imaging is unremarkable. While navigating and intervening upon multiple distal posterior vessels presents significant technical hurdles, concurrent endovascular therapy in these territories is safe, technically viable, and can offer profound functional recovery.Disclosures M. Langman: None. D. Lim: None. K. Jan: None. J. Nerva: 2; C; Medtronic. 4; C; Synchron, Inc, Borvo Medical, Inc, Bendit Technologies, Ltd.Abstract E-210 Figure 1