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A 62-year-old man developed sudden slurring of speech, dysphagia and vertigo and in the emergency department he rapidly became stuporous. A CT angiogram of head showed occlusion of the distal basilar artery trunk (figure 1) and an occluded right vertebral artery at the level of C6 (figure 2). He received intravenous tissue plasminogen activator and a cerebral angiogram showed contrast stasis at the origin of the right vertebral artery, indicating that the occlusion was acute (figure 3). There was partial occlusion of the basilar tip extending into the left P1 segment of the posterior cerebellar artery. During the angiogram, all his symptoms resolved apart from a right homonymous hemianopia, and clot retrieval was not further considered. Distal vasculature showed no evidence of proximal or distal vessel narrowing to suggest atherosclerosis or vasculitis (figure 4).