Medial Medullary Infarction Research Articles

"Y appearance" infarction: caused by essential thrombocythemia.

Essential thrombocythemia (ET) is a myeloproliferative malignancy caused by the excessive proliferation of megakaryocytes in the bone marrow, resulting in the overproduction of peripheral platelets. ET can lead to thrombotic events, such as ischemic stroke (IS), though it is a rare cause of IS. Bilateral medial medullary infarction (BMMI), also known as "Y appearance" infarction due to its distinctive imaging morphology, is a rare clinical subtype of IS which typically has a poor prognosis and a high mortality rate. Herein, we report the case of a 43-year-old male with a history of ET. The patient's platelet count was poorly controlled, and he did not receive regular treatment. After developing symptoms such as dizziness, dysphagia, choking on water, slurred speech, blurred vision, and bilateral limb numbness. Head magnetic resonance imaging revealed a "Y appearance" infarction in the bilateral medial medulla. After admission, the patient was administered intravenous antiplatelet therapy with tirofiban. However, when he was switched to oral aspirin after three days, he experienced decreased muscle strength and worsening symptoms. Therefore, tirofiban was continued for 14 days. Upon discharge, the patient experienced residual limb numbness. His National Institutes of Health Stroke Scale score was 1, Modified Rankin Scale score was 0, and platelet count had decreased to the normal range. During the 9-month follow-up period after discharge, the patient still had only mild limb numbness. Our report presents a special case of "Y appearance" infarction due to ET. Owing to fluctuations in the patient's condition, he received long-term high-dose tirofiban, which ultimately led to a significant improvement in his symptoms.

An analysis of clinical characteristics of rare bilateral medial medullary infarction: An observational study.

This study aimed to characterize the risk factors, etiology, clinical manifestations, anatomical characteristics, stroke mechanisms, imaging features, and prognosis of bilateral medial medullary infarction (BMMI). A retrospective analysis was conducted on 11 patients with BMMI who met the inclusion criteria at the Affiliated Hospital of Xuzhou Medical University from January 2013 to January 2023. The patients' imaging and clinical features were analyzed and summarized. Eleven patients (7 male, 4 female), aged 46 to 62 years, met the inclusion criteria. Common clinical presentations included dysarthria (90.9%), dysphagia (90.9%), quadriplegia (81.8%), and so on. Within 72 hours of onset, 8 cases presented with quadriplegia, 2 cases with hemiplegia, and 1 case without limb paralysis. The main risk factor for BMMI was hypertension, followed by diabetes. "Heart appearance" infarcts occurred in 4 cases (36.4%), while "Y appearance" infarcts occurred in 7 cases (63.6%). Among the patients, 3 had unilateral vertebral artery stenosis or occlusion, 5 had bilateral vertebral artery stenosis or occlusion, 2 had normal vertebral basilar artery, and 1 did not undergo cerebrovascular examination. All patients received standardized treatment for cerebral infarction. The prognosis was poor, with 81.8% of patients having an unfavorable outcome, including 1 death, 9 cases of disability, and only 1 patient achieving self-care ability after recovery. BMMI is more prevalent in males aged 45 to 60 years. The main risk factors are hypertension and diabetes. Atherosclerosis is the primary etiological subtype. The main clinical manifestations are dyskinesia, dizziness, quadriplegia, and dysarthria. The prognosis of BMMI is poor. The specific imaging features of "heart appearance" or "Y appearance" infarcts aid in the diagnosis of BMMI.

A Case Report of a Medial Medullary Infarction Patient with Menopausal Hot Flashes

This case study reports on the effectiveness of Korean medicine treatment for menopausal hot flashes in stroke patients. During hospitalization, a female patient with medial medullary infarction was diagnosed with menopausal hot flashes and received treatment with traditional Korean medicine and acupuncture. The assessment was performed by monitoring daily habits to relieve hot flashes. The hot flash index, menopause rating scale (MRS), menopause-specific quality of life (MENQoL) questionnaire, and Kupperman index (KI) were also used. After 28 days of treatment, the hot flash index improved from 27 to 2, MRS improved from 11 to 2, MENQoL improved from 40 to 21, and KI improved from 22 to 6. Thus, this case suggests that Korean medicine treatment may be effective for menopausal hot flashes in stroke patients.

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.

Central positional nystagmus due to acute medial medullary infarction

A 70-year-old male with risk factors for vascular disease presented with dizziness and instability. The patient showed horizontal geotropic nystagmus when turning his head while lying down, with larger slow phase velocity observed when turning to the left. There were no other neurological deficits. Video head impulse tests and vestibular evoked myogenic potentials were normal. The initial magnetic resonance imaging (MRI) findings were negative; however, the patient experienced subsequent right-side weakness, right tilting, and recurrent episodes of vertigo. A follow-up MRI revealed an acute left medial medullary infarction, which seems to have caused the paroxysmal geotropic central positional nystagmus in this patient.

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.

Complete occlusion of vertebral artery and medial medullary infarction

Complete occlusion of vertebral artery and medial medullary infarction

The diagnostic value of the ocular tilt reaction plus head tilt subjective visual vertical (±45°) in patients with acute central vascular vertigo.

To investigate the localization diagnostic value of the ocular tilt reaction (OTR) plus head tilt subjective visual vertical (SVV) in patients with acute central vascular vertigo (ACVV). We enrolled 40 patients with acute infarction, 20 with unilateral brainstem infarction (BI) and 20 with unilateral cerebellar infarction (CI). We also included 20 patients with unilateral peripheral vestibular disorders (UPVD) as the control group. The participants completed the OTR and SVV during head tilt (±45°) within 1 week of symptom onset. In patients with ACVV, including that caused by lateral medullary infarction (100%, 2/2), partial pontine infarction (21%, 3/14), and cerebellum infarction (35%, 7/20), we observed ipsiversive OTR, similar to that seen in UPVD patients (80.0%, 16/20). Some of the patients with medial medullary infarction (50%, 1/2), partial pons infarction (42%, 6/14), midbrain infarction (100%, 2/2), and partial cerebellum infarction (30.0%, 6/20) showed contraversive OTR. The skew deviation (SD) of the BI group with ACVV was significantly greater than that of the UPVD group (6.60 ± 2.70° vs. 1.80 ± 1.30°, Z = -2.50, P = 0.012), such that the mean SD of the patients with a pons infarction was 9.50° and that of patients with medulla infarction was 5.00°. In ACVV patients with no cerebellar damage, the area under the curve of the receiver operating characteristic curve corresponding to the use of SD to predict brainstem damage was 0.92 (95%CI: 0.73-1.00), with a sensitivity of 100% and a specificity of 80% when SD ≥ 3°. We found no statistical difference in SD between the UPVD and CI groups (1.33 ± 0.58° vs. 1.80 ± 1.30°, Z = -0.344, P = 0.73). Compared with the UPVD patients, the ACVV patients with a partial pons infarction (43%, 6/14, χ2 = 13.68, P = 0.002) or medulla infarction (25%, 1/4, χ2 = 4.94, P = 0.103) exhibited signs of the ipsiversive E-effect with the contraversive A-effect, while those with a partial medulla infarction (50%, 2/4), pons infarction (43%, 6/14), or cerebellar infarction (60%, 12/20) exhibited a pathological symmetrical increase in the E-effect. The evaluation of OTR plus head tilt SVV (±45°) in vertigo patients is helpful for identifying and diagnosing ACVV, especially when SD is ≥ 3° or the E-effect is symmetrically increased.

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.

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".

Anatomic and MRI bases for medullary infarctions with patients’ presentation

ObjectiveThere is a low incidence of the medullary infarctions and sparse data about the vascular territories, as well as a correlation among the anatomic, magnetic resonance imaging (MRI) and neurologic signs. Materials and methodsArteries of the 10 right and left sides of the brain stem were injected with India ink, fixed in formalin and microdissected. The enrolled 34 patients with medullary infarctions underwent a neurologic, MRI and Doppler examination. ResultsFour types of the infarctions were distinguished according to the involved vascular territories. The isolated medial medullary infarctions (MMIs) were present in 14.7%. The complete MMIs comprised one bilateral infarction (2.9%), whilst the incomplete and partial MMIs were observed in 5.9% and 8.9%, respectively. The anterolateral infarctions (ALMIs) were very rare (2.9%). The complete and incomplete lateral infarctions (LMIs), noted in 35.3%, comprised 11.8% and 23.6%, respectively, that is, the anterior (5.9%), posterior (8.9%), deep (2.9%), and peripheral (5.9%). Dorsal ischemic lesions (DMIs) occurred in 11.8%, either as a complete (2.9%), or isolated lateral (5.9%) or medial infarctions (2.9%). The remaining ischemic regions belonged to various combined infarctions of the MMI, ALMI, LMI and DMI (35.3%). The infarctions most often affected the upper medulla (47.1%), middle (11.8%), or both (29.5%). Several motor and sensory signs were manifested following infarctions, including vestibular, cerebellar, ocular, sympathetic, respiratory and auditory symptoms. ConclusionsThere was a good correlation among the vascular territories, MRI ischemia features, and neurologic findings regarding the medullary infarctions.

Progression rates of medulla oblongata infarcts in clinical follow-up: A retrospective study

ObjectiveTo determine clinical progression rates in patients with medulla oblongata infarction (MOI). Materials and methodsThe data of patients diagnosed with MOI were analysed retrospectively. Dermographic characteristics of the patients; Age, gender, history and stroke etiology were evaluated. Radiological imagings were reviewed retrospectively. Intensive care unit (ICU) requirement, number of intubation days, failed extubation and death rates, good clinical outcome at discharge and 3 months [modified Rankin Scale (mRS 0–2)] and poor clinical outcome (mRS 3–6) rates were evaluated. In addition, the clinical results of patients with medial medullary infarction (MMI) and lateral medullary infarction (LMI) were compared. Results33 patients were included in the study, 22 (66.7 %) were male. The mean age of the patients was 72.0 (43.0–85.0). The characteristics of the patients (dermographic features, comorbidities, clinical symptoms, infarct localization, etc.) were evaluated. The results of MMI and LMI patients were compared. The intubation rate was 4 (44.4 %) in the MME group, while it was 8 (33.3 %) in the LME group. There was no statistically significant difference between the two groups in terms of failed extubation, tracheostomy, hospitalization and mortality rates. However, while discharge mRS was statistically significant between the two groups, the mRS at 3 months was not statistically significant. Twelve (36.4 %) of all patients were intubated due to severe clinical progression. In the clinical follow-up, 6 (50.0 %) of the intubated patients died, 3rd month mRS of 6 (50.0 %) patients who survived was 5. In all patients 3-month good clinical outcome rate was % 48,5. ConclusionIt should not be forgotten that life-threatening clinical progressions may develop at a considerable rate during the early treatment process of patients diagnosed with MOI.

The Heart Shape-Sign in the Brainstem

Bilateral medial medullary syndrome is a rare type of stroke, which results due to occlusion of the anterior spinal artery or vertebral artery or its branches. Clinical diagnosis without neuroimaging is very difficult; the characteristic brain MRI finding of “heart appearance” at DWI has been described in bilateral medial medullary infarct. We report the case of 53-year-old man with acute onset quadriparesis. MRI scan of brain, diffusion weighted (DW) imaging revealed heart shaped hyper-intensity areas in the bilateral medial medulla.

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.

Highest resolution microCT scan of the human brainstem reveals putative anatomical basis for infrequency of medial medullary syndrome

Ischemic strokes affecting the medial medulla are exceedingly rare. The anatomical basis for the relative infrequency of this stroke syndrome has been largely uninvestigated due to historically coarse MRI and CT scan resolution. We capture and digitally dissect the highest-ever-resolution diffusible iodine-based contrast-enhanced CT (diceCT) scanned images of a cadaveric brainstem to map arterial territories implicated in medial medullary infarctions. 3D reconstructions show that within the anterior spinal artery territory previously implicated in medial medullary syndrome (MMS), there are numerous, small sulcal artery branches perforating the medulla within the anterior median fissure. These branches proceed in parallel through the anteroposterior depth of the medulla as expected; however, we also identify a network of intraparenchymal, rostrocaudal anastomoses between these sulcal perforating branches. This network of intraparenchymal sulcal artery anastomoses has never been described and may provide a significant collateral supply of oxygenated blood flow throughout the medial medulla. By ramifying deeper tissues, these anastomoses can help explain the infrequency of MMS.

Teaching Video NeuroImage: Spontaneous Upbeat-Torsional Nystagmus From Medial Medullary Infarction.

A 71-year-old man presented with acute dizziness and right-sided paresthesia. Examination revealed spontaneous torsional nystagmus (top pole of eyes beating to the left) with a milder upbeat component (Video 1), right-sided weakness, and right hemisensory loss. MRI brain showed an acute left medial medullary infarct (Figure). Spontaneous upbeat-torsional nystagmus typically results from selective damage to the vertical semicircular canal pathways in the medullary medial longitudinal fasciculus (MLF), often resulting in an ipsilesional-beating torsional nystagmus.1 It is important to note that extra-MLF lesions in the brachium conjunctivum and ventral tegmental tract can also produce similar findings (Figure).1,2 Although upbeat-torsional nystagmus is more commonly observed in posterior canal benign paroxysmal positional vertigo, it is elicited by the Dix-Hallpike maneuver and is not continuous or spontaneous.

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.