Objective:

We present a case illustrating a “reverse locked-in syndrome,” characterized by persistent almost total ophthalmoplegia with a normal motor exam following basilar artery thrombectomy.

Background:

First coined by Raibakgar et al, the term “reverse locked-in syndrome” described an uncommon presentation associated with endovascular recanalization of the top of the basilar artery. Basilar artery occlusions are classically associated with locked-in syndrome, wherein the patient is quadriplegic with horizontal gaze palsies but retains vertical eye movements.

Design/Methods:

An 87-year-old male presented with acute-onset coma and mid-basilar occlusion. On arrival, he exhibited forced eye closure, global aphasia, and movement of all extremities in the plane of the bed. Despite non-compliance with outpatient rivaroxaban and thrombolysis not being considered, he underwent thrombectomy achieving TICI 3 recanalization. Postprocedural neurological exams and imaging, including MRI and CT angiogram, were performed to evaluate brain infarction and vascular status.

Results:

Post-thrombectomy, the patient demonstrated midline gaze with complete ophthalmoplegia in all directions but was able to follow commands and lift all extremities without drift. MRI revealed symmetric acute medial bithalamic and biventral tegmentum midbrain infarcts suggestive of Percheron territory infarction, though the artery of Percheron was not visualized. Five days after the procedure, the patient showed improved mentation, verbal output, and strength (at least 4/5 in all extremities), but remained ophthalmoplegic except for minimal leftward gaze; rightward, upward, and downward gaze remained plegic with absent oculocephalic reflex.

Conclusions:

This case highlights a rare presentation of “reverse locked-in syndrome” after basilar artery thrombectomy, characterized by near-complete ophthalmoplegia despite preserved motor function, contrasting the classical locked-in syndrome phenotype.