Signs and symptoms of basilar artery occlusion vary depending on the extent (but also the site) of the occlusion. Unlike the majority of cerebrovascular insults, the clinical course is frequently gradual and starts with relatively mild and nonspecific complaints such as a headache and possibly vertigo, which mimics a transient ischemic attack (TIA) and delays the diagnosis [1] [2] [3]. Eventually, the typical signs of basilar artery occlusion appear - altered mental state (patients are often in a coma), hemiparesis or quadriparesis, dysphagia, dysarthria, and other neurological deficits [1] [2] [3] [4]. Additional findings that could be encountered are nausea, vomiting, bulbar dysfunction, locked-in syndrome, ataxia, deficits of the extraocular muscles, and nystagmus, as well as the hearing loss [1] [2] [3] [4]. Epileptic-like events characterized by bilateral twitching or shaking may be present [2]. Specific symptoms appear in relation to the site of occlusion [5]. For example, occlusion of the middle segment of the basilar artery (which supplies the lateral and medial pons) can result in ipsilateral loss of sensation of the face, dysmetria, and contralateral hemiparesis [5]. Studies that have investigated basilar artery occlusion in both children and adults show a marked predominance of male gender [3] [4].

• Refractory Shock

  Despite aggressive surgery, sepsis persisted, and therapy was limited by uncontrollable coagulopathy and catecholamine refractory shock after 15 days. [ncbi.nlm.nih.gov]

• Flushing

  Heparin was only applied for catheter flushing (500 IU/h). The patient with the atherothrombotic occlusion was treated with additional percutaneous transluminal angioplasty and stenting. [ncbi.nlm.nih.gov]

• Tinnitus

  Hypaesthesia or anaesthesia •Cerebellar signs •Vertigo,nausea, vomiting, directional nystagmus •Disturbance of respiration, blood pressure and heart rate •Headache, •Incontinence •Oculomotor signs •Facial palsy •Double vision, strabismus, skew deviation •Tinnitus [omicsonline.org]

  Major neurological symptoms include deafness on the affected side, the weakness of facial muscles, dizziness true (system), nausea and vomiting, nystagmus, tinnitus, and cerebellar ataxia, Horner's syndrome, paresis of horizontal gaze. [minclinic.ru]

  […] mentioned in table 2 included “malaise,” described as a sensation of impending death or general uneasiness in 10 patients; breathing difficulties in four patients; abnormal movements referred to as “seizures” in five patients; and sudden hearing loss or tinnitus [jnnp.bmj.com]

• Suggestibility

  The evidence suggests that embolization was the operating pathogenic mechanism of cerebral vascular occlusion. [ncbi.nlm.nih.gov]

• Claustrophobia

  Claustrophobia is another important adverse factor when using MRI as an imaging study. [symptoma.com]

• Alteration of Consciousness

  Clinical symptoms included nausea, vomiting, and rapid alteration of consciousness. Magnetic resonance imaging showed total occlusion of the basilar artery, and angiography confirmed VAD from the third to the fourth segments. [ncbi.nlm.nih.gov]

• Thalamic Pain

  CLINICAL FEATURES Basilar artery occlusion at the bifurcation: cortical blindness impaired short term memory pupillary abnormalities gaze palsies thalamic pain syndromes there should not be bulbar dysfunction (unless there is propagation of the occlusion [lifeinthefastlane.com]

• Fluctuating Level of Consciousness

  Fig. 2 A 54-year-old man with hypertension and dyslipidemia presented with nausea and vomiting, fluctuating left-sided weakness, and a fluctuating level of consciousness. [karger.com]

Because of the insidious onset of symptoms, the physician must suspect basilar artery occlusion if any of the abovementioned manifestations are observed. Cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, or prior vascular insults are present in a number of patients [3], meaning that a fully obtained patient history can be of great help in raising clinical suspicion. The neurological exam, however, is the crucial component of the workup, as a detailed assessment of cranial nerve and brainstem functions might reveal the exact site of the lesion [2]. To make a definite diagnosis, imaging studies need to be employed. Computed tomography (CT) is usually the first-line study in patients who exhibit stroke-like symptoms, but the location of the basilar artery is a significant barrier for adequate CT imaging [5]. On the other hand, magnetic resonance imaging (MRI) is a more suitable study that can delineate the soft tissues in more details, particularly through diffusion-weighted imaging (DWI). Importantly, the procedure is time-consuming and is contraindicated for patients with pacemakers or foreign bodies made of metal [5]. Claustrophobia is another important adverse factor when using MRI as an imaging study [5]. Studies recommend conventional catheter cerebral angiography, and either CT and MR angiography, as these procedures provide a precise view of the desired blood vessels [5] [6]. MR angiography with contrast is particularly useful for evaluation of vertebrobasilar vessels [6].

1. Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol. 2011;10(11):1002-1014.
2. Demel SL, Broderick JP. Basilar Occlusion Syndromes: An Update. Demaerschalk BM, ed. Neurohospitalist. 2015;5(3):142-150.
3. Israeli-Korn SD, Schwammenthal Y, Yonash-Kimchi T, et al. Ischemic stroke due to acute basilar artery occlusion: proportion and outcomes. Isr Med Assoc J. 2010;12(11):671-675.
4. Goeggel Simonetti B, Ritter B, Gautschi M, et al. Basilar artery stroke in childhood. Dev Med Child Neurol. 2013;55(1):65-70.
5. Nouh A, Remke J, Ruland S. Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management. Front Neurol. 2014;5:30.
6. Khan S, Rich P, Clifton A, Markus HS. Noninvasive detection of vertebral artery stenosis a comparison of contrast-enhanced MR angiography, CT angiography, and ultrasound. Stroke. 2009;40(11):3499–3503.