Abstract
Bilateral vertebral artery disease presents a critical risk for posterior circulation stroke due to impaired collateral flow. This report details an adult presenting with acute neck pain and visual disturbances. Computed tomography (CT) angiography revealed left vertebral artery dissection at the C2 level with a 0.5 cm dissecting pseudoaneurysm and complete occlusion of the right vertebral artery. Magnetic resonance imaging (MRI) demonstrated no acute infarction. Symptoms improved with conservative management, including antiplatelet therapy. The case highlights the importance of recognizing high‐risk bilateral vertebral artery pathology, understanding its imaging features, and considering substance abuse as a risk factor for arterial dissection. This case is notable for V3 dissecting pseudoaneurysm in the only functional vertebral artery in the setting of chronic contralateral occlusion and recent methamphetamine use, successfully managed conservatively.