An 82-year-old man presented with recurrent, short-lasting episodes of left-sided weakness and left homonymous hemianopia. MRI revealed right pontine, cerebellar & occipital ischemia associated with basilar artery stenosis on CT Angiography. He arrived within the thrombolytic window and was treated with intravenous alteplase. Despite initial improvement, he developed post-thrombolysis neurological fluctuations. Rescue therapy with intravenous tirofiban was initiated and continued for 48 hours, resulting in marked clinical stabilization without hemorrhagic transformation and was planned for further stenting on follow up and continued on dual antiplatelet therapy with statins. Unfortunately, due to lack of follow-up for 4 months and definitive revascularization, the patient succumbed from a fatal brainstem infarction.

This case highlights the diagnostic and therapeutic challenges of PWS, a manifestation of branch atheromatous disease. The stereotyped, transient nature of symptoms can delay diagnosis, increasing the risk of irreversible infarction. While early reperfusion with intravenous thrombolysis and adjunctive tirofiban prior to intervention as a bridging measure may stabilize neurological deficits, definitive management of underlying basilar artery stenosis is crucial for long-term outcomes.