Status Epilepticus as a Red Flag for Basilar Artery Occlusion: Clinical Clues From a Systematic Review

Abstract

Basilar artery occlusion (BAO) is a catastrophic ischemic stroke with subtle initial manifestations. Although convulsive‐like movements are well recognized in brainstem ischemia, true status epilepticus (SE) as the presenting sign of BAO is exceedingly rare and frequently misdiagnosed. This study presents an illustrative case of SE with early posterior circulation ischemic changes highly suggestive of BAO, and a systematic review to identify confirmed cases of BAO presenting with SE, clarify diagnostic pitfalls, and outline bedside “red flags” prompting urgent posterior circulation imaging. A PubMed/Scopus search (September 2025) was performed using predefined terms for basilar artery occlusion and status epilepticus. Inclusion required imaging‐confirmed BAO and SE; SE was defined according to ILAE/Salzburg definitions. Clinical, electroencephalographic, therapeutic, and outcome data were extracted and critically analyzed. Six patients met the inclusion criteria, including focal motor, generalized convulsive, and non‐convulsive SE (two early, one established, two refractory, and one non‐convulsive SE). Benzodiazepine resistance occurred in half of the cases. Despite successful reperfusion in two patients, all survivors had poor outcomes. True SE can herald BAO across multiple phenotypes, but it appears rare and is frequently confounded by mimics. Diagnostic “red flags” include new‐onset SE in adults without a history of epilepsy, early benzodiazepine resistance, brainstem signs, pupillary abnormalities, and the “looking away from the seizure” sign. Recognition of BAO‐related SE as a vascular stroke equivalent, often representing a Stage 1 Plus SE, may suggest early posterior circulation imaging to avoid fatal delays in reperfusion.