Report of Two Cases: Altered Mental Status and Anisocoria as Presenting Symptoms in Acute Basilar Artery Occlusion

TL;DR

Two cases show altered mental status and unequal pupils can signal a rare but serious brainstem stroke, requiring urgent treatment.

Contribution

Highlights anisocoria and mental status decline as rare but critical signs of acute basilar artery occlusion.

Findings

Altered mental status and anisocoria were presenting symptoms in two cases of acute basilar artery occlusion.

Early suspicion of basilar artery occlusion is crucial for timely interventions like thrombolytics or thrombectomy.

Posterior circulation strokes can mimic traumatic brain injury due to similar clinical signs.

Abstract

A posterior circulation stroke at the level of the basilar artery can cause ischemia to the brainstem, cerebellum, and occipital lobes. Posterior circulation strokes are notoriously more difficult to clinically diagnose than anterior circulation strokes, with a variety of presenting symptoms including altered mental status, dizziness, vision changes, nausea, and vomiting. Anisocoria has been reported to occur in rare cases.

We present two cases where patients had an acute episode of altered mental status with a key exam finding of anisocoria, or unequal pupil sizes. The combination of anisocoria and acute mental status decline are classically associated with traumatic brain injury, increased intracranial pressure, or both. In each of the two cases presented, acute basilar artery occlusion was seen on computed tomography with angiography.

When presented with acute decline in mental status and anisocoria, early clinical suspicion of an acute basilar artery occlusion is crucial in diagnosing and managing these patients with debilitating acute posterior stroke. Time-sensitive interventions such as thrombolytics and mechanical thrombectomy can be lifesaving.

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