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Background: In acute ischemic stroke (AIS), neuropsychological deficits and their long-term impact are insufficiently studied. We studied pure aphasic AIS patients, their short-term aphasiological course, predictors of persisting aphasia, and their outcome., Methods: In the ASTRAL Registry, we assessed all pure aphasic AIS patients from 2003-2019, and reviewed their neuropsychological examination performed after 3-10 days. We identified factors associated with persistent significant aphasia in the subacute phase, and predictors of unfavourable functional outcome at 3 months (mRS≥ 2), using multivariate analyses (MVA)., Results: Among 4513 consecutive AISs, 131 (2.9 %) had pure aphasia at admission. Eighty-one had a good quality neuropsychological examination and were analysed further (median age 76.3yrs; 44.4 % female; 6.2 % left-handed; 27.2 % treated by acute revascularization). Of these, 28.4 % still had significant aphasia in the subacute phase. Persistent aphasia was independently associated with cardioembolic (OR 13.6, 95 %CI 2.6-70.8) or atheromatous (OR 16.0, 95 %CI 1.9-132.1) stroke mechanisms, and with an executive function deficit on neuropsychological examination (OR 10.5, 95 %CI 2.0-54.4). At 3 months, female gender (OR 4.2, 95 %CI 1.2-15.3) and significant aphasia in the subacute phase (OR 12.0, 95 %CI 3.3-43.6) predicted an mRS≥2., Conclusion: Pure aphasia was present in 2.9 % of all AIS patients and resolved in three-quarters in the subacute phase. Persistent aphasia was associated with embolic stroke mechanisms and concomitant executive function impairment, and poor 3 months outcome, with female gender and enduring subacute aphasia. These data may help with prognostication, management and rehabilitation planning., Key Message: Pure aphasic ischemic stroke is rare and most recover spontaneously within days, and persistent subacute aphasia is associated with defined embolic stroke mechanisms, and concomitant executive dysfunction. Unfavourable functional outcome at 3 months is present in women and if there is persistent subacute aphasia., Competing Interests: Declaration of competing interest The authors have no potential conflicts of interest with respect to research, authorship and publication of this article., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)