Introduction Chronic bilateral occlusion of the internal carotid and vertebral arteries is a rare condition that carries a high risk of severe ischemic strokes and mortality. Prognosis depends on the capacity of collateral circulation to sustain adequate cerebral perfusion, and management requires an individualized approach that accounts for each patient's current neurological status, vascular anatomy, and associated comorbidities. This case report highlights the critical role of collateral pathways in maintaining cerebral perfusion despite extensive cerebrovascular occlusions and shows that conservative medical therapy alone may be an effective therapeutic approach in selected patients. Methods We present the case of a 60‐year‐old man who had a stroke with full clinical recovery and was found to have bilateral internal carotid and vertebral artery occlusion of presumed atherosclerotic origin, managed medically and followed for one year. Results A 60‐year‐old man with a past medical history of type 2 diabetes and hypertension presented to our institution after a 15‐minute episode of right hemiparesis and facial asymmetry, resolving spontaneously. Blood pressure was 150/70 mmHg, Neurological exam was normal, NIHSS = 0. Imaging showed bilateral hyperintensities at the ACA‐MCA junction on DWI and FLAIR MRI, reflecting hypoperfusion lesions. CTA showed left ICA occlusion, right ICA sub‐occlusion, bilateral occlusion of the V0 and V1 segments of the vertebral artery, dilated cervical arteries, and dilated ophthalmic arteries with retrograde flow, confirmed by Doppler ultrasound. EKG showed a normal sinus rhythm. The final diagnosis was bilateral hemodynamic stroke with complete clinical recovery. Acute Management included dual antiplatelets (aspirin and clopidogrel), statins, 5 days of anticoagulation, and permissive hypertension maintained at 160‐170 mmHg. The patient remained clinically stable with no neurological deterioration. Anticoagulation was stopped after 5 days, and the patient was discharged on dual antiplatelet therapy, high‐intensity statins therapy, and low‐dose amlodipine. Long‐term targets were BP 150‐160 mmHg, and LDL≤ 0.7g/l. Surgical and endovascular approaches were considered; however, the severely pathological state of the arteries and the risk of worsening cerebral hypoperfusion made these options prohibitively high‐risk, favoring conservative medical management. At one‐year follow‐up, he remained clinically stable with no recurrent ischemic events or neurological deficits under continued medical therapy. Conclusion This rare case of simultaneous bilateral occlusion of the internal carotid arteries (BICAO) and vertebral arteries (BVAO) underscores the critical role of collateral networks in sustaining cerebral perfusion and demonstrates that, in selected patients, optimal medical therapy alone may be sufficient to maintain complete neurological recovery. Careful collateral assessment is therefore essential to guide treatment decisions and predict outcomes in severe cerebrovascular disease.
Maniar et al. (Sat,) studied this question.