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Phenytoin (diphenylhydantoin) is a widely used antiepileptic drug for controlling both generalized and partial seizures. Reversible cerebellar symptoms, including cerebellar ataxia, have been recognized as an adverse event of phenytoin use for many years. On the other hand, cerebellar degeneration has been reported with chronic use in an epileptic patient treated with this drug. We are reporting an interesting case of phenytoin induced acute pan-cerebellar syndrome with cerebellar atrophy on neuro-imaging that improved many years after discontinuation of the drug. Discontinuation of phenytoin may give a chance for the patient to recover slowly, months after stopping the drug. It is very important for the attending neurologist to educate the patients and their families on some common clinical manifestations suggestive of drug toxicity and perform a regular follow-up and clinical examination at regular intervals.

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Strokes in the territory of the posterior cerebral artery (PCA) may rarely cause acute confusion or delirium, especially when bilateral or the dominant PCA are involved. Delirium as the only initial presentation of basilar artery thrombosis (with no brainstem or long tract findings) is an extremely rare occurrence. In this article, the clinical presentation of our case was an acute confusion with septic shock-like features (tachycardia, hypotension, and leukocytosis) for a few days without any focal deficit. These symptoms pointed more toward a non-focal neurological cause, especially meningoencephalitis. This case highlights the importance of detailed history and thorough evaluation of high-risk patients who present with an acute devastating neurological syndrome. In addition, knowledge of the atypical presentation of stroke should be acquired, and the limitation of an unenhanced computed tomography scan of the brain without vascular imaging should be known. Investigating patients with a sudden acute confusion should be directed toward the evaluation of the etiology in a stepwise manner. However, the pace of investigations should be fast to establish the diagnosis and optimize the outcome.

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