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Transient Ischemic Attack Progressing to Top-of-the-Basilar Syndrome: A Case Report
1Department of Neurology, Jiangyin People's Hospital Affiliated to Nantong University, Jiangyin, Jiangsu, China.
The American Journal of Case Reports
|August 7, 2026
Summary
Top-of-the-basilar syndrome (TOBS) can present with diverse symptoms before and during treatment. This case highlights transient coma during recombinant tissue plasminogen activator (rt-PA) for TOBS, emphasizing the need to differentiate stroke progression from hemorrhage.
Area of Science:
- Neurology
- Vascular Neurology
- Neurocritical Care
Background:
- Top-of-the-basilar syndrome (TOBS) is a rare posterior circulation disorder.
- It involves acute ischemia in territories supplied by the distal basilar artery.
- Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is a treatment option.
Purpose of the Study:
- To report a rare case of transient coma during rt-PA infusion for TOBS.
- To illustrate the diverse and rapidly changing clinical presentation of TOBS.
- To emphasize the importance of differentiating stroke progression from hemorrhagic transformation.
Main Methods:
- Case report of a 77-year-old male with cardiogenic TOBS.
- Diagnosis confirmed via head and neck CT angiography and MRI.
- Treatment administered with intravenous rt-PA.
- Serial neuroimaging (CT, MRI, MRA) to monitor changes.
Main Results:
- The patient experienced transient visual hallucinations, dysarthria, and hemiparesis.
- Abrupt, self-limiting loss of consciousness occurred 50 minutes into rt-PA infusion.
- MRI confirmed incomplete TOBS with infarcts in the thalami, hippocampus, and cerebellum.
- MRA showed resolution of P1 stenosis but new P2 segment narrowing.
Conclusions:
- Clinical symptoms of cardiogenic TOBS are diverse and can evolve rapidly.
- Neurological deterioration during thrombolytic therapy requires prompt evaluation.
- Distinguishing between stroke progression and hemorrhagic transformation is critical.
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