Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 9 4 2025 02 22 180 185 EN Leila Afshar Hezarkhani Department of Neurology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran. AND Neuroscience Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran. Payam Sariaslani Department of Neurology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran. AND Neuroscience Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran. Fatemeh Feyzi Medical Faculty, Kermanshah University of Medical Sciences, Kermanshah, Iran. Milad Mohamad Yari Department of Neurology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran. AND Neuroscience Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran. 2024 12 13 2024 12 31 Top of the Basilar Syndrome (TOBS) is a rare neurological condition caused by occlusion of the distal basilar artery, often resulting in significant morbidity. TOBS is particularly challenging to diagnose in younger patients with atypical risk factors. A 34-yearold man presented with vertigo following strenuous exercise. Initial misdiagnoses delayed treatment, and subsequent imaging revealed left vertebral artery dissection and basilar artery occlusion. Endovascular thrombectomy performed 41 hours and 45 minutes after symptom onset achieved a Thrombolysis in Cerebral Infarction (TICI) score of 2B. Despite complications, including hydrocephalus and pneumonia, multidisciplinary management led to significant recovery, with the patient’s modified Rankin Scale (mRS) score improving from 4 at discharge to 1 at one year. This case underscores the importance of clinical vigilance, advanced imaging, and endovascular thrombectomy in managing TOBS. Even with delayed intervention, multidisciplinary care can facilitate favorable outcomes in young patients with rare presentations. https://crcp.tums.ac.ir/index.php/crcp/article/view/1007 https://crcp.tums.ac.ir/index.php/crcp/article/download/1007/681