A 50-year-old man presented with a 1-year history of worsening fatigue and bitemporal headaches. He denied focal neurologic symptoms, but complained of constant dizziness which was exacerbated when he went from a lying to a standing position. Sometimes he experienced syncopal episodes, and a complete syncope workup thus far had been negative. Carotid duplex ultrasound suggested chronic occlusion of his left internal carotid artery (ICA), with a 70% to 99% stenosis of his right ICA. Carotid duplex ultrasound also showed elevated velocities in his external carotid arteries (ECAs) bilaterally indicating significant stenosis.