1. “Basilar stenosis plus” J. Maestre M.D. Neurology Service. Stroke Unit Hospital Virgen de las Nieves Granada. Spain (Posted on 03/20th/2010)

2. Male, 42 y/o, dislipemic, heavy smoker and drinker. Two years ago language impairment and right side hemiparesis with spontaneous improvement. Did not seek for medical advice. Two weeks ago dizzines and left visual disfunction. Ocasional diplopia since then. MRI: left frontotemporal old infarct, acute occipital infarct (right PCA territory). Doppler studies, MR-angio, and angiography: left ICA occlusion at the siphon level. Right ICA 75 % stenosis postbulbar. Preocclusive basilar stenosis in its middle third. Right PCA supply is from basilar artery. Both MCAs and ACAs depend from the right ICA; left PCA depends from left ICA through PcoA (corrected from the original post)

3. Thus: Old symptomatic left ICA intracranial occlusion. Asymptomatic right ICA 75 % cervical stenosis, this artery supplying both hemispheres except PCAs. Critical (preocclusive) symptomatic basilar stenosis. What would you reccomend: 1) Medical treatment (quit smoking and alcohol, statins, antiplatelets –one or two?-) 2) Medical treatment plus basilar percutaneous transluminal angioplasty (PTA)-stenting? 3) Medical treatment plus right ICA carotid stenting (CAS) or carotid endarterecthomy (CEA)? 4) Medical treatment plus basilar PTA-stenting plus right ICA CAS or CEA? Any other approach?

4. DW / MRI

5. T2 W / MRI

6. T1 W / MRI

7. Left ICA Right ICA

8. Left VA Basilar (magnification)