Abstract Number ‐ 185: Variable Presentation of Basilar Occlusion: Lessons to be Learned

Abstract

Introduction To present a case of basilar thrombosis with lessons for improving care. Methods Case presentation Results 89 year old Female with history of coronary artery disease with prior stenting brought in by ambulance for cardiac arrest. Patient last known normal 0900 per son. At 1100 patient called EMS for sudden onset nausea with projectile emesis. On arrival EMS staff noted patient to be walking and talking and administered zofran. After eight to ten minutes staff witnessed patient undergo cardiopulmonary arrest and initiated cardiac compressions. Return of spontaneous cardiac activity achieved after one dose of epinephrine and two minutes of compressions. In emergency department at 1132 patient moving extremities and following commands but intubated for encephalopathy and hypoxia. Computed Tomography (CT) head without contrast performed at 1222 showed hypodensity in left occipital lobe and left cerebellum suspicious for infarct. Neurology consulted routinely and National Institute of Health Stroke Scale (NIHSS) 21. Stat CT angiography of head and neck completed at 1657 and showed complete occlusion of basilar artery from origin to terminus. Patient evaluated by neurology fellow and found to be unresponsive with decerebrate posturing, NIHSS maximal; Neurosurgery service was paged at 1659 for stat evaluation. Patient arrived at cath lab at 1949 and thrombectomy performed with TICI 2b. Magnetic Resonance Imaging of brain performed next day at 432 showed diffuse diffusion restriction and T2 signal in bilateral occipital lobes, temporal lobes and thalami, throughout midbrain and pons consistent with acute/subacute infarct. Patient was transitioned to comfort care and extubated. Conclusions Acute basilar occlusion is recognized as a potentially treatable condition if diagnosed quickly. Outcomes of these infarcts remain poor but recent evidence from ATTENTION and BOAChE studies has shown that treatment by emergent thrombectomy provides for better outcomes than medical management alone despite higher risk of intracranial hemorrhage and that these benefits can be seen after 12 to 24 hours from symptom onset(1,2). This particular case is unique not only due to the rarity of stroke presenting as intractable emesis but also in its illustration of diagnostic pitfalls of posterior circulation (3,4). In order to provide appropriate treatment, recognition of abnormal presentation of basilar thrombosis becomes increasingly important. Paul et al identified isolated vertigo, vertigo with non‐focal symptoms, isolated double vision, transient generalized weakness, and binocular visual disturbance as significant transient symptoms preceding basilar occlusion (5). Savitz and Caplan report, “most common signs are limb weakness, gait and limb ataxia, oculomotor palsies, and oropharyngeal dysfunction” but also note that vomiting, vertigo, visual loss, numbness can also occur (6). Additionally this patient initial CT scan showed possible stroke but did not identify vessel occlusion. Developments in artificial intelligence are working towards identifying large vessel occlusion on plain noncontrast CT which would have benefitted this patient.