Beware the Basilar: A Case of Stuttering Stroke Symptoms and an Unusual Aftermath

Background: Basilar thrombus is an uncommon but important stroke syndrome. The objective of this clinical case is to highlight the often subacute nature of presentation and an unexpected complication. Case presentation: A 60-year-old man presented with sudden onset dysarthria and left sided weakness of his face, arm and leg having felt unsteady on his feet for the 2 days prior to admission. Initial CT head and CT angiogram demonstrated no acute ischaemic change or haemorrhage and no thrombus. An hour later his left side became densely weak and he developed dense right sided facial and leg weakness. Repeat CT angiogram demonstrated absent flow in the basilar artery and the diagnosis of ischaemic stroke secondary to basilar thrombus was made. During his admission he developed severe rectal pain and was treated and investigated for prostatitis. MRI prostate excluded infection but demonstrated a very dilated rectum and pseudo-obstruction of his colon and he was diagnosed with neurogenic bowel as a consequence of pontine infarction. Learning points: Basilar thrombus can present with stuttering symptoms, prodromal symptoms and progress from unilateral to bilateral weakness with airway compromise. Consideration should be given to the diagnosis of neurogenic bowel in patients with significant abdominal symptoms.