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Top of the basilar syndrome

Case contributed by Frank Gaillard
Diagnosis almost certain

Presentation

Patient woke with vertigo and subsequently (over next hour) developed cranial nerve symptoms (ocular palsies) and decreased level of consciousness.

Patient Data

Age: Elderly
Gender: Male
ct

The top of the basilar artery is hyperdense. 

CT angiogram

ct

CTA performed 20 minutes later confirms a filling defect involving the basilar tip and left P1 and SCA origin. The distal PCA fills via the PCOM. 

Post IV tPA

ct

Despite IV tissue plasminogen activator (tPA), a left superior cerebellar infarct is now visible. 

CT brain 24 hours later

ct

Follow up CT confirms the evolution of a left-sided superior cerebellar artery infarct with substantial positive mass effect and developing hydrocephalus. 

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