BACKGROUND: Cocaine use is a well-known contributing factor for both ischemic and hemorrhagic stroke; however, basilar artery thrombosis due to cocaine use is a rare entity with few cases reported in the literature.

CASE REPORT: A 75-year-old African-American man with history of hypertension and cocaine use presented to the emergency room with coma. Neurological examination revealed asymmetrical dilated pupils and preserved oculocephalic and gag reflexes. The patient was noted to have semi-rhythmic jerking movement of the right arm and extensor posturing in response to noxious stimuli. Non-contrast computed tomography (CT) of the brain showed hyperdense basilar sign consistent with acute thrombosis. On brain magnetic resonance imaging (MRI), he was found to have bilateral pons acute ischemic stroke with early petechial hemorrhagic conversion. His laboratory work-up was unremarkable except for positive cocaine in the urine toxicology screen test.

CONCLUSIONS: Cocaine is a common global illicit drug that may trigger acute basilar artery thrombosis leading to a catastrophic neurological outcome.

Keywords: Basilar Artery, Cocaine - adverse effects, Diagnosis, Differential, Fatal Outcome, Magnetic Resonance Imaging, Thrombosis - diagnosis, Tomography, X-Ray Computed