Sudden bilateral anterior cerebral artery (ACA) infarction is very rarely reported in the literature. We describe a 38-year-old male smoker and heavy alcohol user, who awoke with sudden onset of weakness of both lower limbs, and bladder and bowel incontinence. He had consumed excessive amounts of alcohol the previous night. There was no significant past medical history including other vascular risk factors and cardiovascular disease. On admission, he was mute and abulic. The frontal release signs including the forced grasping and the snout reflex were present. Routine full blood count and biochemical analysis were normal. MRI of the brain showed bilateral, nearly symmetrical ACA infarction (figure 1A–C). Time-of-flight magnetic resonance angiography (figure 1D) on admission showed supraclinoid internal carotid artery occlusion bilaterally. A CT angiogram performed the next day (figure 1E) revealed recanalised middle cerebral arteries bilaterally. The relatives were not willing to allow a digital subtraction angiogram to be performed. Electrocardiogram and transthoracic echocardiogram were within normal limits. Work up …