Spinal artery infarcts (SCIs) comprise 1-1.5% of all ischemic strokes, the majority of which are traumatic. Of all SCIs, both traumatic and spontaneous, anterior spinal artery infarcts are most common. Identified risk factors for nontraumatic SCIs include hypertension, atherosclerosis, aortic dissection, and iatrogenic procedures.  However, most studies pool both anterior and posterior spinal artery (PSA) SCIs together.  

 In 2018, The Mayo Clinic published the largest analysis of spontaneous SCIs. Of the 133 spontaneous SCIs reported, only 15 patients had PSA infarctions, one of which was less than 50-years-old.  

PSA infarcts are exceedingly rare, accounting for less than 0.2% of ischemic strokes. As in our patient, the vague presenting symptoms of PSA infarcts could potentially lead to a delay in diagnosis; therefore, we postulate that the incidence may be higher than reported. Spontaneous VA dissections are also rare, with over 90% of dissections propagating intracranially. Our case is unique, as it illustrates a rare sequela of bilateral VA dissections leading to unilateral PSA infarction.   

Early identification of spontaneous bilateral VA dissections and increased awareness of the easily overlooked potential sequelae of PSA infarctions would facilitate efforts to mitigate diagnostic delay and ensure appropriate management.