“A storm in the middle” evolution of a lateral medullary syndrome to a bilateral medial medullary infarct: A case report

Abstract

Introduction Posterior circulation infarction accounts for about 20–25% of all ischemic strokes in the general adult population. Medial medullary infarction (MMI) is reported to be less than 1% of vertebrobasilar artery strokes, with only 18% of such cases occurring bilaterally to involve both medial side of the medulla. Objective To present a rare case of Wallenberg syndrome evolving to a bilateral medial medullary infarct. Case: A 55-year old, hypertensive, male complaining of sudden onset vertiginous dizziness and non-projectile vomiting with initial manifestation of right pseudoptosis, sensory deficit on the right side of the face, unequal palatal elevation, weak gag reflex with no sensorimotor deficit. However, progression of symptoms was noted during hospitalization. Patient became quadriplegic with inability to protrude tongue and impaired deep sensations. MRI and CTA were done. Results Cranial MRI result revealed acute bilateral medial medullary infarcts corresponding to the pyramidal tracts, along the vascular territories of the medullary perforating branches of the vertebral arteries. Angiographic results revealed “short segment narrowing at the M1-M2 junction of the right middle cerebral artery territory (R MCA) and in the territories of right vertebral artery (R VA)”. Conclusion Bilateral medial medullary infarction is a rare stroke which has a poor clinical outcome. Though it occurs due to an atheromatous occlusion of a distal Vertebral Artery, it can also be preceded or occurred simultaneously with Wallenberg Syndrome. Diagnosis of such combination warrants vigilance, thorough neurologic examination and a high suspicion together with the aid of MRI to arrive with the accurate neurologic diagnosis.