Fluctuating Neurological Deficits in Severe Proximal Basilar Artery Stenosis: Conservative Management or Endovascular Angioplasty?

Abstract

Introduction : Symptomatic basilar artery (BA) stenosis is a high-risk cause of posterior circulation ischemia with potential for recurrent events despite optimal medical therapy. The decision between conservative treatment and endovascular angioplasty remains challenging, particularly in patients with fluctuating symptoms.

Case Report : A 62-year-old man with hypertension, poorly controlled type 2 diabetes mellitus, and prior ischemic stroke presented with a two-month history of oscillopsia, intermittent headache, and transient left-sided weakness. Symptoms progressed to persistent imbalance, diplopia, and gait instability. Brain imaging demonstrated acute infarctions in the left thalamus and right anterior pons, multiple chronic posterior circulation infarcts, occlusion of the right vertebral artery, and severe proximal BA stenosis. Digital subtraction angiography (DSA) confirmed approximately 90% symptomatic proximal BA stenosis with reduced flow to the right anterior inferior cerebellar artery. Despite risk factor control, the patient continued to experience symptoms that significantly interfered with daily activities. Given the high procedural risk, conservative management was chosen with close monitoring. A three-month observation period with repeat DSA was planned to reassess the need for angioplasty.

Discussion : This case highlights the unstable course of severe BA stenosis despite medical therapy. Although angioplasty may improve perfusion, BA interventions carry substantial risk due to brainstem perforators, with perforator infarction from “snow-plow” effect during angioplasty being a major concern, particularly in proximal lesions.

Conclusion : Severe symptomatic BA stenosis presents a challenging therapeutic dilemma. Short-term observation with planned reassessment may be appropriate, but progressive symptoms require close follow-up and early consideration of endovascular treatment.