A 35-year-old man presented to the emergency department with altered mental status and bilateral tonic-clonic seizures. Due to a progressive decrease in consciousness, he was intubated for airway protection. The patient's relatives reported that he had used cocaine, leading to an initial suspicion of acute cocaine intoxication. However, a head CT scan without contrast revealed a hyperdense basilar artery sign without other signs of infarction (Figure 1). Furthermore, DWI-MR imaging revealed multiple areas of infarction within the vertebrobasilar arterial circulation (Figure 2). Despite not showing occlusion of vertebral or basilar arteries, cerebral angiographic imaging was performed. Unfortunately, the patient was not diagnosed with acute stroke timely and therefore did not receive appropriate treatment. Eventually, after a few months, he was diagnosed with brain death in the intensive care unit.
Stroke misdiagnosis is common in young patients without vascular risk factors.(1) Moreover, cocaine use should not be considered a seizure risk factor, warranting further diagnostic studies.(2) Lastly, some patients with cocaine-induced stroke may have routine cerebral angiography due to the vasoconstriction-induced infarction mechanism.(3) In this patient, premature closure bias based on clinical and radiological features of cocaine-induced stroke resulted in delayed diagnosis.