Basilar artery fenestration is an uncommon congenital variant that has been associated with aneurysms and posterior circulation infarcts in the adult literature. Little is known about the functional consequences of basilar artery fenestration, if any, in childhood. We present a case of a previously healthy 12-year-old boy who presented with diplopia, tinnitus, and ataxia who had subtle findings on diffusion-weighted magnetic resonance imaging consistent with posterior circulation territory infarction. Computed tomography angiography and magnetic resonance angiography revealed an area of signal abnormality in the basilar artery, which was confirmed on conventional angiography to be a type 2 basilar artery fenestration, without thrombus or aneurysm. The patient recovered from his neurologic deficits over two days and was placed on prophylactic aspirin therapy without recurrence of symptoms. This rare anatomic variant of the posterior circulation is important for physicians to recognize and may have associated neurologic consequences during childhood worthy of further investigation. 1. Introduction Basilar artery fenestration is an uncommon congenital variant present in upwards of 5% of the general population and has been associated with aneurysms in the adult literature [1]. However, the significance of this finding is unknown in the pediatric literature. We present a case of a young boy with acute neurological deficits in association with this rare anatomical variant. 2. Case Report A previously healthy 12-year-old Asian boy presented with a chief complaint of episodic double vision and tinnitus. His symptoms began with a one-day history of headache and neck pain, followed by acute intermittent double vision and tinnitus. Over the next day, the patient noticed he had some difficulties with speech, together with some very mild R-sided weakness and imbalance that brought him to the emergency room. The patient denied any trauma or recent illness. Vital signs and general examination were unremarkable. On neurologic examination, he had mild lateral and upward gaze-evoked nystagmus, mild right-sided hemiparesis, and right-sided dysmetria. A noncontrast head computed tomography (CT) was normal, and the patient was admitted to the intensive care unit for concerns for a stroke or postinfectious/demyelinating disease. Magnetic resonance imaging showed punctate areas of reduced diffusivity in bilateral cerebellar hemispheres (see Figure 1). Both CT and MR angiography showed an area of abnormality of the basilar artery at the level of the anterior inferior
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