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INTRODUCTION. Atherosclerotic occlusion of the brachiocephalic trunk (CBT) is a rare clinical entity and its presentation in the form of arterio-arterial embolism is uncommon. Early identification of patients with CBT occlusion may have important therapeutic implications. CASE REPORT. A man aged 49 presents with sudden onset symptoms involving the territory of the right middle cerebral artery. Emergent transcranial doppler evaluation showed a flow pattern of proximal right M1 occlusion. After intravenous recombinant tissue plasminogen activator administration, partial recanalization of the vessel was found and the patient improved clinically. Cervical and transcranial duplex sonography demonstrated an occlusion in CBT, which was later confirmed on CT angiography and digital angiography of supraaortic vessels. After aorto-innominate bypass, pathological analysis confirmed the atherosclerotic origin. CONCLUSIONS. The most common clinical presentation of CBT occlusion are transient ischemic symptoms related to steal phenomenon in the vertebro-basilar territory. Symptoms of carotid circulation stroke usually result from arterio-arterial embolic mechanism. Early recognition is important for its therapeutic implications, therefore thrombolytic therapy should be indicated. Neurosonologic study allows rapid and reliable examination on hemodynamic status and the presence of distal embolic phenomena.