Clinical Review & Education Images in Neurology Top of the Basilar Syndrome Presenting With Convulsions William L. Conte, MD; Chandler E. Gill, MD; Jose Biller, MD A man in his 60s presented with impaired level of alertness, convulsive-like movements of the limbs, and vertical nystagmus. Initial imaging findings were consistent with top of the basilar artery occlusion (Figure 1). He received intravenous tissue plasminogen activator and was brought for an attempted endovascu- lar intervention. Thrombectomy was not successful owing to a tortuous vertebral artery, although there was already partial recanalization of the basilar artery from the intravenous tissue plasminogen activator. Subsequent magnetic resonance imaging showed bilateral occipital-temporal, thalamic, and cerebellar Figure 1. Initial Imaging of the Basilar Artery Occlusion A Axial noncontrast CT B Axial CT angiography C Axial CT angiography D Coronal CT angiography E Digital subtraction angiography A, Axial noncontrast computed tomography (CT) showing hyperdense basilar artery (arrowhead). Axial (B and C) and coronal (D) CT angiography showing occlusion of the distal basilar artery with proximal preservation (arrowheads). E, Digital subtraction angiography showed recanalization of the basilar artery after intravenous tissue plasminogen activator but progression of the clot into both posterior cerebral arteries. Figure 2. Magnetic Resonance Imaging of Ischemic Changes A Representative cut 1 B Representative cut 2 C Representative cut 3 Axial diffusion-weighted magnetic resonance images showing extent of the supratentorial and infratentorial ischemic changes. jamaneurology.com (Reprinted) JAMA Neurology Published online December 19, 2016 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://archneur.jamanetwork.com/ by a GAZI UNIVERSITESI User on 12/20/2016 E1 Clinical Review & Education Images in Neurology hemispheric infarctions (Figure 2). In the hospital, he was found to have paroxysmal atrial fibrillation. At the end of his hospitalization, he had a left visual field deficit, left hemibody weakness, and ARTICLE INFORMATION Author Affiliations: Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois. left hemibody ataxia. His weakness improved during rehabilitation. Convulsive-like activity can be an initial presentation of an impending basilar artery occlusion.1,2 Corresponding Author: William L. Conte, MD, Department of Neurology, Loyola University Chicago, 2160 S First Ave, Maywood, IL 60153 (billy .conte@gmail.com). Published Online: December 19, 2016. doi:10.1001/jamaneurol.2016.3449 Conflict of Interest Disclosures: None reported. E2 REFERENCES 1. Caplan LR. “Top of the basilar” syndrome. Neurology. 1980;30(1):72-79. 2. Matsuo K, Fujii C, Fuse I, Nakajima M, Takada M, Miyata K. Top of the basilar syndrome in a young adult initially presenting with a convulsive seizure. Intern Med. 2011;50(13):1425-1428. JAMA Neurology Published online December 19, 2016 (Reprinted) Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://archneur.jamanetwork.com/ by a GAZI UNIVERSITESI User on 12/20/2016 jamaneurology.com