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We report a stroke patient with tandem occlusion of both the distal middle cerebral artery (MCA) and the ipsilateral internal carotid artery (ICA) who clinically deteriorated after intravenous thrombolysis in spite of recanalization of the ICA because of new proximal MCA (main-stem) occlusion. We discuss this unfortunate course (clinical deterioration in spite of partial recanalization) in the light of the characteristics of human brain vasculature and argue in favour of a more aggressive reperfusion strategy in this special setting