Neurocritical Care

, Volume 27, Issue 1, pp 108–114 | Cite as

Reverse Locked-In Syndrome

  • Pooja Raibagkar
  • Ram V. Chavali
  • Tamara B. Kaplan
  • Jennifer A. Kim
  • Meaghan V. Nitka
  • Sherry H.-Y. Chou
  • Brian L. EdlowEmail author
Practical Pearl



Basilar artery occlusion can cause locked-in syndrome, which is characterized by quadriplegia, anarthria, and limited communication via eye movements. Here, we describe an uncommon stroke syndrome associated with endovascular recanalization of the top of the basilar artery: “reverse locked-in syndrome.”


We report the case of a patient with atypical neurological deficits caused by acute ischemic stroke of the midbrain tegmentum. We perform neuroanatomic localization of the patient’s infarcts by mapping the magnetic resonance imaging (MRI) data onto a brainstem atlas.


A 61-year-old man presented with acute coma and quadriplegia due to top of the basilar artery occlusion. He underwent emergent endovascular thrombectomy, with successful recanalization of the basilar artery at 4 h and 43 min post-ictus. The patient regained consciousness and purposeful movement in all four extremities, but the post-procedure neurological examination demonstrated bilateral ptosis with complete pupillary and oculomotor paralysis. MRI revealed infarction of the bilateral oculomotor nuclei in the midbrain tegmentum. At 9-month follow-up, he had anisocoria and dysconjugate gaze, but was living at home and required minimal assistance in performing all activities of daily living.


Since the patient’s deficits were the exact opposite of those described in locked-in syndrome, we propose the term “reverse locked-in syndrome” to describe this neurological entity characterized by bilateral ptosis, non-reactive pupils, and ophthalmoplegia with preservation of consciousness and extremity motor function.


Top of the basilar artery Locked-in syndrome Midbrain tegmentum Endovascular thrombectomy Ophthalmoparesis 



This work was supported by the National Institutes of Health (K23NS094538), American Academy of Neurology/American Brain Foundation, and the James S. McDonnell Foundation.

Compliance with ethical standards

Conflict of interest

Sherry H.-Y. Chou: National Institutes of Health/National Institute of Neurological Disorders and Stroke (K23-NS073806), University of Pittsburgh Physicians Research Grant, serves as the site principal investigator for Newton II clinical trial funded by Edge Therapeutics. Pooja Raibagkar, Ram V. Chavali, Tamara B. Kaplan, Jennifer A. Kim, Meaghan V. Nitka, Brian L. Edlow: nothing to disclose.


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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Pooja Raibagkar
    • 1
  • Ram V. Chavali
    • 2
  • Tamara B. Kaplan
    • 1
  • Jennifer A. Kim
    • 1
  • Meaghan V. Nitka
    • 3
  • Sherry H.-Y. Chou
    • 4
  • Brian L. Edlow
    • 1
    • 5
    Email author
  1. 1.Department of NeurologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Department of RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Department of Emergency MedicineLowell General HospitalLowellUSA
  4. 4.Departments of Critical Care Medicine, Neurology, and NeurosurgeryUniversity of Pittsburgh School of MedicinePittsburghUSA
  5. 5.Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General Hospital, Harvard Medical SchoolCharlestownUSA

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