Unexpected preserved brain perfusion imaging despite severe and diffuse atherosclerosis of supra-aortic trunks

We report an unusual case of a patient whose whole cerebral circulation was supported by poor vicariate collaterals and a severely atherosclerotic right vertebral artery, with no brain perfusion abnormalities. Our belief is that despite the brain imaging and the absence of symptoms, because of his critical vascular disease and the paucity of data from large randomised clinical trials on vertebra-basilar revascularisation, the case required an extremely cautious approach regarding any kind of revascularisation. An accurate imaging analysis together with clinical features allowed us to decide on a strategy based on optimal medical therapy and careful clinical monitoring.