BACKGROUND: A 40-year-old man presented to an emergency department with slurred speech, diplopia and agitation several hours after cocaine use. His level of consciousness rapidly dropped in the hours following presentation. INVESTIGATIONS: Physical examination, CT scan of the head, cerebral angiography. DIAGNOSIS: Cocaine-induced basilar artery thrombosis. MANAGEMENT: Intra-arterial thombolysis, mechanical clot aspiration, intravenous abciximab, neurointensive care support, rehabilitation at a specialist stroke unit.