Bilateral Medial Medullary Infarction Research Articles

Medial medullary infarction: clinical, radiological findings and long-term prognosis.

Medial medullary infarction (MMI) is a rare type of posterior circulation stroke. We aim to examine the clinical and radiological features, etiology, and prognosis of patients with MMI. MMI patients registered consecutively in the stroke databank of the Istanbul Medical Faculty between January 1999 and April 2022 were included in the study. Medullary lesions were rostrocaudally classified as rostral, middle, and caudal, and ventrodorsally as ventral, middle, and dorsal. The etiological classification was performed, and functional outcome was assessed based on the modified Rankin Scale (mRS). Overall survival was estimated using the Kaplan-Meier technique. We examined 48 cases of MMI including 9 with bilateral MMI. There were 34 men (70%), and mean age was 62.9 (± 12.8) years. The median NIHSS score was 7 (IQR; 4.5-10.5). The most common symptom was motor dysfunction. The medullary lesions were located caudally in 4 patients, rostrally in 30, rostromedially in 10, and rostro-medio-caudally in 2 patients. On ventro-dorsal classification; unilateral lesions were found ventrally in 19, ventromedially in 11, and ventro-medio-dorsally in 4 patients. The median follow-up duration was 20months (interquartile range (IQR); 1-60). According to the third-month mRS, 39% of the patients were considered to have a good prognosis. The most common etiology was distal vertebral artery atherosclerosis. More than 50% of the patients could walk unassisted in the long-term follow-up, and stroke recurrence was infrequent. Patients with bilateral MMI had poor outcomes.

Bilateral medial medullary infarction due to varicella‐zoster virus vasculopathy: A case report

AbstractBilateral medial medullary infarction (MMI) is a rare form of ischemic stroke, mainly caused by vertebral artery atherosclerosis or small penetrating artery disease. We report a case of bilateral MMI due to varicella‐zoster virus (VZV) vasculopathy. An 81‐year‐old man presented with altered consciousness and right hemiplegia during disseminated herpes zoster. Polymerase chain reaction analysis of his cerebrospinal fluid detected positive VZV‐DNA, and magnetic resonance imaging revealed ischemic infarction localized to the ventral part of the bilateral medial medulla and enhancement of the left vertebral artery. After initiating intravenous acyclovir administration, his consciousness, skin rashes, and general condition improved gradually, whereas pyramidal symptoms deteriorated into quadriplegia. This case demonstrates that VZV vasculopathy may cause bilateral MMI.

Bilateral Medial Medullary Infarction: The Airpod Sign.

Bilateral Medial Medullary Infarction: The Airpod Sign.

The stroke mechanism, clinical presentation, and radiological feature of bilateral medial medullary infarction.

Bilateral medial medullary infarction (BMMI) is a rare type of posterior circulation stroke. The aim of this study is to characterize its stroke mechanisms, clinical manifestations, neuroradiological features, and prognosis. From January 2015 to June 2021, a retrospective review of 15 patients diagnosed with BMMI was conducted. The clinical and neuroradiological features were summarized by our experienced neurologists. Fifteen patients (12 male, 3 female), ranging in age from 48 to 72years, satisfied the inclusion criteria. The common clinical presentations included motor weakness (100%), deep sensory disturbance (93.3%), vertigo/dizziness (80%), dysarthria (93.3%), and dysphagia (66.7%). Vertically, infarct lesions in the rostral medulla were observed in all included patients. Horizontally, "heart appearance," "Y appearance," and "fan appearance" infarcts occurred in 9 cases (60%), 5 cases (33.3%), and 1 (6.7%) case, respectively. Patients (53.3%) had severe stenosis or occlusion in unilateral vertebral artery (VA), and 33.3% had normal findings in the vertebrobasilar artery. Patients (93.3%) achieved poor prognosis. BMMI is more frequently located in the rostral medulla and comprises three forms of infarction. The two main stroke etiologies of BMMI are large-artery atherosclerosis (LAA) and small vessel disease (SVD). BMMI is always associated with bad clinical outcome.

A Case of Bilateral Medial Medullary Syndrome

Bilateral Medial medullary syndrome is a very rare form of posterior circulation strokes due to occlusion of the anterior spinal artery or vertebral artery. In this case report we present a patient who presented with bilateral medial medullary infarction. Keywords: Posterior circulation stroke, Bilateral medial medullary syndrome.

Intravenous Thrombolysis in a Rare Case of Bilateral Medial Medullary Infarction

Based on our PuBMed and Cochrane search, this is the first case report that describes the clinical outcome of thrombolysis in a rare case of bilateral medial medullary infarction. OBJECTIVE: To describe the outcome of thrombolysis in a frequently devastating bilateral medial medullary infarction. CLINICAL PRESENTATION: A 37-year-old Chinese male was seen at the emergency department four hours from symptom onset of sudden and rapidly progressing bilateral motor weakness with associated dizziness. The patient was seen awake, not in cardiorespiratory distress. Pupils were 3 millimeters isocoric and briskly reactive to light. Extraocular muscle movements were full and equal and there was torsional nystagmus on all gazes. There was right central facial palsy and weak gag reflex bilaterally. Tongue was midline on protrusion. Motor strength test revealed right sided hemiplegia and left sided hemiparesis (2-/5 on MMT). Bilateral Babinski sign was elicited. There was no sensory deficit to light touch. Magnetic resonance imaging of the brain showed acute infarction of the bilateral anteromedial medulla. TREATMENT AND OUTCOME: Alteplase was given at a dose of 0.7 mg/kg was given at exactly 4.5 hours post-ictus. There was no complication after thrombolysis. He was discharged on the 12th day post-ictus, still with dizziness but with improved muscle strength on all extremities to 3/5 MMT except for the right arm which remained paralyzed. He was able to tolerate oral feeding and had a Modified Rankin Scale score of 4.

Intestinal Pseudo-Obstruction Caused by Bilateral Medial Medullary Infarction.

Intestinal Pseudo-Obstruction Caused by Bilateral Medial Medullary Infarction.

Bilateral Medial Medullary Infarction with Stenosis of Hypoplastic Vertebral Artery: Typical "Heart and Y Shapes".

Bilateral Medial Medullary Infarction with Stenosis of Hypoplastic Vertebral Artery: Typical "Heart and Y Shapes".

The Heart Shape-Sign in Bilateral Medial Medullary Infarction; Complicated with Quadriparesis and Respiratory Failure

20% of ischemic strokes involve posterior circulation. The most common causes of posterior circulation large artery ischemia are atherosclerosis, embolism, and dissection. The most common location of atherosclerotic occlusive disease within the posterior circulation is the proximal portion of the vertebral artery in the neck within the first inches. Basilar artery occlusive disease most often presents as ischemia in the pons. Occlusion of the rostral portion of the basilar artery can cause ischemia of the midbrain, thalami, temporal, and occipital lobe. The most frequent finding in patients with PCA territory infarction is a hemianopia.

The utility of “heart sign” on neuroimaging in acute-onset quadriparesis: A series of three cases

The “heart sign” is a well-described radiological sign in bilateral medial medullary infarction, which is a rare stroke syndrome. It has also been rarely reported in infarction of bilateral paramedian pons and caudal paramedian midbrain. Bilateral brainstem infarcts usually present with varying degree of quadriparesis and in the initial stages, it is difficult to distinguish from other conditions such as Guillain–Barre syndrome and brainstem encephalitis. Recognizing the “heart sign” on magnetic resonance imaging in a stroke-like episode may be helpful in differentiating these conditions from bilateral brainstem infarcts.

Bilateral Medial Medullary Infarction (Dejerene Syndrome) Patient Suffering from Quadriplegia Treated by Korean Traditional Medicine: a Case Report

Bilateral Medial Medullary Infarction (Dejerene Syndrome) Patient Suffering from Quadriplegia Treated by Korean Traditional Medicine: a Case Report

Heart sign in Neurology - A Radiological sign

Bilateral medial medullary infarction is a rare stroke syndrome. The common symptoms are quadriparesis, dysarthria and hypoglossal palsy. However, the early diagnosis of bilateral medial medullary infarction may be difficult as it may mimic other conditions like Guillain Barre syndrome and brainstem encephalitis. With the advent of magnetic resonance imaging, it can be easily diagnosed, as the diffusion weighted sequences demonstrate hyperintensity involving bilateral medulla in a heart shaped pattern, described as the “Heart sign”. We hereby report a patient who presented with progressive quadriparesis, and dysarthria, progressing to respiratory failure, whose MRI brain showed the characteristic “heart sign” on diffusion sequences and was diagnosed to have bilateral medial medullary infarction.

Heart in the brain: classical imaging sign in bilateral medial medullary infarction

Bilateral medial medullary infarction is a rare type of posterior fossa stroke due to occlusion of blood supply to the anteromedial aspect of the medulla. It can be diagnosed by its classical imaging appearance - the "heart sign".

Fabry disease presenting as bilateral medial medullary infarction with a \u201cheart appearance\u201d sign: a case report

BackgroundThe etiologic determinants of cryptogenic stroke remain a diagnostic challenge in clinical practice. Fabry disease (FD) is one of the monogenic causes of stroke that may remain unrecognized as a potential contributing causative factor, because of its rarity and difficulty in diagnosis. We report a case with rare bilateral medial medullary infarction manifesting as “heart appearance” who was diagnosed with FD.Case presentationA 51-year-old Chinese man presented with acute dysarthria and mild tetraparesis. In the 24 h following admission, the patient rapidly developed progressive flaccid quadriplegia and tongue weakness, necessitating ventilator support. Immediate magnetic resonance imaging of the brain showed heart-shaped appearance of bilateral medial medullary infarction. The patient suffered two new subcortical infarcts 40 days after the first. Detailed Family history and physical examination indicated symptoms consistent with FD, which was confirmed by very low alpha galactosidase A levels and a missense mutation of the alpha-galactosidase A gene.ConclusionsWe report what appears to be the first case of FD manifesting as bilateral medial medullary infarction. Our case suggests that clinicians should consider the possibility of FD in patients with cryptogenic stroke, especially when combined with infarction in the vertebrobasilar artery system, renal insufficiency, or cardiomyopathy. A detailed analysis of subtle historical clues and performing a complete physical examination on stroke patients would help promote earlier diagnosis of FD.

Giant \u201cheart appearance-like sign\u201d on MRI in bilateral ponto-medullary junction infraction: case report

BackgroundBilateral medial medullary infarction (MMI) is uncommon and bilateral medial pons infarction (MPI) is even rarer. “Heart appearance” on magnetic resonance imaging (MRI) is a characteristic presentation of bilateral medial medullary infarction (MMI).Case presentationWe present 67-year-old Chinese diabetic and hypertensive female patient affected with “heart appearance-like” infarction in bilateral ponto-medullary junction on MRI. Abnormal signal was observed in the bilateral ponto-medullary junction on T1, T2, fluid-attenuated inversion recovery and apparent diffusion coefficient (ADC). The whole brain digital subtraction angiography (DSA) showed the basilar artery and vertebral artery remained intact. Therefore, we speculated that the bilateral ponto-medullary junction infarction might be caused by the deep perforating branch of the basilar artery.ConclusionsAs far as we know, the “heart appearance-like” infraction in bilateral ponto-medullary junction was not reported. Our case also suggests that bilateral ischemic infraction involvement of the medulla and pon is possible even in the context of an intact basilar artery.

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

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.

Clinical features of two cases of bilateral medial medullary infarction

Clinical features of two cases of bilateral medial medullary infarction

Clinical Study of 27 Patients with Medial Medullary Infarction

Medial medullary infarction (MMI) is a rare ischemic stroke. Frequency of each neurological finding in MMI was different in each study. We retrospectively evaluated the medical records of patients with cerebral infarction who were admitted between March 1998 and October 2015. Patients in our study were diagnosed as having MMI by magnetic resonance image examination. Of 2727 patients with ischemic stroke, 27 patients (20 males and 7 females) had MMI. The MMI was complicated by infarcts located in the pons (n = 6), cerebellum (n = 2), and lateral medulla (n = 1). One patient had bilateral MMI. Large-artery atherosclerosis was the most common etiology. Motor weakness of the extremities was the most common neurological finding. Diminished contralateral superficial sensation was more common than diminished contralateral vibratory sensation, and these 2 types of sensory disturbance were often complicated. The patients with large MMI significantly more often accompanied diminished touch (P = .003), pain (P = .017), and vibratory (P = .019) sensation. Facial weakness was shown more common contralateral to the infarcts than ipsilateral (n = 8 contralateral, n = 1 ipsilateral). Lingual palsy was also more common contralateral to the lesions (n = 3 contralateral, n = 1 ipsilateral). One patient alone fulfilled the classical Dejerine triad. In MMI, motor weakness of extremities was commonly shown, and complication of diminished sensations indicated the large infarcts. As for facial weakness and lingual palsy, the supranuclear type was more prominent than the infranuclear type.

The heart of the matter: Acute quadriplegia with respiratory paralysis - bilateral medial medullary infarction

The clinicoradiologic correlate of bilateral medial medullary infarction is described. This is a rare clinical entity of vertebrobasilar stroke syndrome with catastrophic consequences and a poor functional prognosis. Since the initial symptom is quadriplegia, the clinical diagnosis without neuroimaging can be challenging with a potential for misdiagnosis as Guillain–Barre syndrome or brainstem encephalitis in the early stages. The teaching neuroimage of the “heart appearance” sign is revisited.

Bilateral medial medullary infarction with a "heart appearance" sign.

Bilateral medial medullary infarction with a "heart appearance" sign.