A 78-year-old African American woman with a past medical history of hypertension, hyperlipidemia, hypothyroidism and transient ischemic attack presented with sudden onset spinning sensation, dizziness, generalized weakness and blurry vision. Her systolic blood pressure at home was around 170 mmHg. On arrival to the ER, her symptoms had resolved completely. Physical and neurologic exam were unremarkable. CT head without contrast was normal. MRI brain revealed mild microvascular ischemic changes and age-related atrophy, with no evidence of acute infarct. MRA head and neck showed congenital atresia of the bilateral internal carotid arteries in the neck with absence of the bilateral petrous carotid canals, along with dominant bilateral vertebral arteries, which provided adequate blood flow to the intracranial circulation.

The imaging findings seen in our case suggest that bilateral agenesis of the internal carotid artery does not increase the risk for cerebrovascular events and is an anatomical variant compatible with life.