A 22 years-old woman referred for episodes of hyperventilation and stiffness in the four limbs. She also reported a transient right ear tinnitus, paresthesia in right half face and hand the same morning. Her family mentioned a story of anxiety disorder with self-harm treated with sertraline, while cardiovascular risk factors, estroprogestinic assumption or drug abuse were excluded.
At neurological examination patient appeared mutacic, with dystonic posturing at four limbs and without any signs of other functional systems involvement, while urgent CT scan was normal. She underwent a psychiatric evaluation which ended up for acute anxiety crisis and was admitted to Psychiatry. In the following 48 hours patient reported a decline in consciousness, with fever and desaturation. A second brain CT scan revealed no abnormalities, while electroencephalogram excluded metabolic or irritative etiology. Cerebrospinal spinal fluid examination was unremarkable. Brain MRI revealed a large subacute infarct involving the width of pons and part of mesencephalus and medulla oblungata, due to basilar artery occlusion extended for 18 mm, which was further confirmed by angioCT. However vascular studies showed no clear signs of disseption or fibromuscular dysplasia and hypercoagulation and cardiac investigations did not disclose any significant contributing factor.