• Sang Hee Ha, Hyug-Gi Kim, and Bum Joon Kim.
• Department of Neurology.
• Medicine (Baltimore). 2020 Aug 7; 99 (32): e21530.

RationaleBasilar artery (BA) fenestration is a congenital anomaly with duplicated BA, which can cause ischemic stroke. However, the stroke mechanism is not clearly verified in patients with BA fenestration.Patient ConcernsHere, we report a case of 64-year-old man with well-controlled hypertension admitted with dysarthria, only.DiagnosesDiffusion weighted image showed a bilateral symmetric pontine infarction sparing the midline. BA fenestration was observed from magnetic resonance angiography.InterventionHigh-resolution magnetic resonance image (MRI) and 4D flow MRI was performed to verify the mechanism of stroke associated with BA fenestration.OutcomesNo plaque was observed at the area of BA fenestration from high-resolution MRI. 4D flow MRI showed bifurcated flow with high flow velocity and low shear stress at the area of BA fenestration.LessonsA turbulent flow with high flow velocity and low shear stress at the BA fenestration area may have influenced the flow through the bilateral perforating arteries resulting in a bilateral symmetric pontine infarction with sparing the midline where the septa of BA is located. 4D flow dynamic studies may be beneficial for verifying the mechanism of stroke.

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