Top of basilar syndrome

Case contributed by Frank Gaillard


Fall. Unequal pupils. Unconcious.

Patient Data

Age: 70 years

A hyperdense basilar artery is noted, consistent with acute thrombotic or embolic disease at the basilar tip with occlusion at the basilar tip on the CT angiographic images (not shown) There is hypoattenuation and loss of grey-white matter differentiation at the left posterior cerebral artery territory consistent with established infarction. This is reflected in the perfusion images with marked prolongation of Tmax and reduced CBF/CBV (not shown). There is also some hypoattenuation at the thalamus on the left and probably involving the left side of the midbrain.


The procedure was performed under general anesthetic.

Hypoplastic right vertebral artery and dominant left vertebral artery. Angiogram confirms mid-basilar occlusion. 

Endovascular clot retrieval of basilar tip occlusion using ADAPT and Solumbra techniques. TICI 3 reperfusion. No angiographic complications.

Acute infarcts are demonstrated in the pons, midbrain, bilateral thalamic nuclei and left PCA territory, compatible with post-endovascular treatment of basilar tip occlusion.

Case Discussion

Despite impressive diffusion changes, the patient was discharged to neuro-rehab. 

It is essential that the possibility of top of basilar syndrome be considered in patients presenting with sudden changes in level of consciousness. A hyperdense basilar tip is a key finding. 

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