Case report of a bilateral medial medullary infarct complicated with tetraplegia and respiratory failure

• Published in: Medicine, case reports and study protocols Vol. 1; no. 2; p. e0039
• Main Authors: Nair, Shaalina, Chai, Low Soon
• Format: Journal Article
• Language: English
• Published: 01.12.2020
• ISSN: 2691-3895; 2691-3895
• DOI: 10.1097/MD9.0000000000000039

Abstract Rationale: Medial medullary infarction is an uncommon stroke resulting from occlusion of a vertebral artery or its branch to the anterior spinal artery and it involves the pyramid, the medial lemniscus, and, sometimes, the hypoglossal nerve. As a result, it is usually described as a triad of ipsilateral hypoglossal paralysis, contralateral hemiparesis sparing the face and contralateral loss of deep sensation. Considering the rarity of the clinical diagnosis and paucity of case reports on this subject, we present a case of a successful detection of a bilateral medial medullary infarct in a patient which was later complicated with tetraplegia and respiratory failure. Patient concerns: This is a 62-year-old gentleman who presented to our center with sudden onset of left sided body weakness, slurring of speech and headache for 3 days. Past medical history includes smoking, hypertension and diabetes mellitus with poor glycemic control. Diagnoses: Subsequently, 3 days later, he developed right sided body weakness with power 0/5 (based on Medical Research Council scale for muscle power assessment) over the right upper and lower limbs with a right hemi sensory loss. Urgent Magnetic Resonance Imaging (MRI) of the brain revealed an acute ‘heart-shaped’ infarct of the bilateral medial medullary regions with a beaded appearance of V4 segment of right vertebral artery and M1 segment of left middle cerebral artery. A diagnosis of bilateral medial medullary infarct was made. Interventions: The patient was then started on oral Aspirin 100 mg once daily and his usual oral antihypertensive, Amlodipine 10 mg per day and oral hypoglycemic medication, Metformin 500 mg twice daily were continued as a part of the risk factor modification. Outcomes: He was tetraplegic and on day 4 post-infract, he developed acute respiratory failure requiring intubation and admission to the intensive care unit. Lessons: A bilateral medial medullary infarct is very rare and we believe that this patient's poorly controlled comorbid conditions have led to progressive atherosclerosis and thrombosis of the right vertebral and left middle cerebral arteries. This patient's respiratory failure is due to the involvement of the medulla oblongata that houses the respiratory center.