Severe Aortic Stenosis and Bilateral Vertebral Artery Stenosis: When “Normal” Blood Pressure Is Not Safe

A 62-year-old woman with poorly controlled type 2 diabetes mellitus and hypertension presented with recurrent syncope, ptosis, diplopia, and focal weakness and was found to have severe aortic stenosis and bilateral vertebral artery stenosis. Despite her “normal” blood pressure and absence of acute infarction on magnetic resonance imaging, her symptoms were attributed to vertebrobasilar hypoperfusion in the setting of exhausted cerebrovascular reserve, consistent with hemodynamic vertebrobasilar disease rather than embolic stroke. Individualized blood pressure targets and multidisciplinary planning allowed safe aortic valve replacement with subsequent complete resolution of syncope and neurologic symptoms.