Top of Basilar Syndrome Presenting With Hyperekplexia Initially Diagnosed as a Convulsive Status Epilepticus

Top of basilar syndrome due to vertebral artery dissection: How high-resolution MRI and CD31 analysis of thrombus could help

INTRODUCTION AND IMPORTANCE

Vertebral artery dissection is a rare but serious condition that can lead to neurological deficits and even death. It is commonly associated with trauma or underlying vascular diseases. Top of basilar syndrome (TOBS) is a neurological condition that can result from vertebral artery dissection, either by direct ischemia or secondary occlusion due to distal embolization of injured inner vascular tissue. We here present a patient who was initially suffering from seizure then had TOBS due to a progressive vertebral artery dissection, with emphasis of high-resolution MRI imaging and immunohistochemistry study of the thrombus.

CASE PRESENTATION

A young male presented to the emergency department with sudden onset of seizure. A history of recent neck exercise was reported. The patient had gaze palsy, adduction disability, and dysarthria. High-resolution MRI showed a vertebral artery dissection with evidence of occlusion of the top of basilar artery. After the thrombectomy, a pathologic study revealed CD31[+] tissue in the thrombus, indicating an origin from dissected vertebral artery.

CLINICAL DISCUSSION AND CONCLUSION

It's important to recognize and treat vertebral artery dissection promptly due to its varying symptoms. Using high-resolution MRI at early stage and conducting pathologic analysis of CD31 on the thrombus can assist in the diagnosis, potentially leading to more precise treatment plans and better outcomes for patients.

Top of the Basilar Syndrome: A Case Report of a Healthy Young Woman and Literature Review

Top of the basilar syndrome (TBS) is defined as the presence of multiple ischemic lesions on magnetic resonance image (MRI) including more than two territories supplied by branches of the distal portion of the basilar artery, causing symptoms such as dizziness, diplopia, ataxia, and acute cognitive decline that can lead to quadriplegia and death. Diagnosing TBS is challenging because it can mimic other conditions such as thalamic hemorrhages or vertebrobasilar ischemia, and requires advanced imaging. Although the prognosis for these patients is poor, rehabilitation is essential for their recovery. This case describes a healthy 28-year-old woman who presented with headache, vomiting, and tonic-clonic seizures sent to the hospital with a stroke diagnosis.

Acute Basilar Artery Occlusion Presenting With Convulsive Movements: A Systematic Review

Background and Purpose: Convulsive seizures related to posterior circulation stroke are considered rare. However, some patients with acute basilar artery occlusion (BAO) can present with convulsive movements. Misdiagnosed as seizures may delay the reperfusion therapy for acute BAO. In this study, we have summarized the clinical features and possible mechanisms of BAO presenting with convulsive movements.

Methods: We performed an Institutional Review Board-approved institutional database query from 2015 to 2020 and a literature search of the online database PubMed. Clinical data were collected and analyzed.

Results: In total, 14 patients with acute BAO presented with convulsions. There were 10 men and 4 women, with a mean age of 53 (range, 23–77) years. All of these patients had different degrees of impaired consciousness (100.0%, 14/14). Convulsive movements were the initial symptoms in 78.6% (11/14) of patients. Further, 64.3% (9/14) of patients presented with paralysis or cranial nerve abnormalities, and 85.7% (12/14) of patients were treated with reperfusion therapy (thrombolysis, 35.7% [5/14]; endovascular thrombectomy, 64.3% [9/14]). The BAO etiology and mechanism were related to embolism, vessel dissections, and severe stenosis of the right vertebral artery in 57.1% (8/14), 21.4% (3/14), and 7.1% (1/14) of patients, respectively; they were undefined in 14.3% (2/14) of patients. Moreover, 42.9% (6/14) of patients had a 90-day modified Rankin Scale score of 0–2, and the mortality rate was 21.4% (3/14).

Conclusions: Acute BAO, especially that related to embolism or vessel dissection, may present with convulsive movements. Acute BAO is a devastating, but treatable disease if diagnosed in time. Considering the possibility of BAO is important when dealing with patients presenting with acute-onset convulsive movements. Prompt diagnosis and reperfusion therapy may help achieve a better prognosis.