Bilateral top of carotid occlusion presenting as basilar thrombosis.

Neurological Institute, Columbia University, New York, N.Y. , USA tremities compatible with multifocal myoclonus in the setting of coma. Small (2 mm) poorly reactive pupils, absent corneal refl exes, absent oculocephalic refl exes and fl accid tetraplegia were also noted. An initial CT scan done within 3 h of onset did not reveal signs of intracranial hemorrhage or brain edema, and the brainstem appeared normal. A presumptive diagnosis of basilar thrombosis was made and the patient was scheduled for an emergent angiogram as soon as his tenuous hemodynamic status improved. After 2 h, when the patient had his hemodynamic status stabilized, a repeat neurological evaluation was done which revealed the same fi ndings as above plus the absence of oculovestibular refl exes on cold water irrigation, but a preserved respiratory drive and gag refl ex. An angiogram was done at approximately 7 h from onset which revealed bilateral top of the ICA occlusion with fi lling of the right and left anterior cerebral arteries through the anterior communicating artery on right ICA injection, no fi lling of either middle cerebral arteries but a fully patent posterior circulation. Both ophthalmic arteries showed complete anterograde fi lling from the ipsilateral ICA injection, and there was a fetal origin left posterior cerebral artery which also fi lled well from a left ICA injection ( fi g. 1 a, b). No endovascular intervention was attempted given the time window and the devastating clinical picture. The patient had persistent brainstem dysfunction on repeat neurological examination and expired 1 day later from progressive hemodynamic failure from a persistently malfunctioning LVAD. An autopsy was performed which revealed a thrombus in the outfl ow tract of the LVAD, bilateral watershed territory infarcts, bilateral ICA occlusions, diffuse brain edema and uncal herniation. Duret’s hemorrhages were identifi ed in the pons and midbrain, compatible with uncal herniation, but no evidence of discrete brainstem infarction was seen. There was no evidence of atherosclerosis in either carotid artery.