Bilateral Medial Medullary Stroke: A Single Center Case Series

Abstract

Introduction. Stroke in the posterior circulation accounts for 20-30% of ischemic strokes (Frid et al., 2019). The medial medullary stroke accounts for less than 1%. It is caused by a lesion in the vertebral artery or its branches, or the anterior spinal artery (Ropper, Samuels, Klein J, & Prasad, 2019). Prognosis depends on the age of the patient and the severity of the motor deficit on admission (Kim & Han, 2019). A bilateral medial medullary infarct is thus very rare. Methodology. We therefore present a case series of three patients in a tertiary hospital in the Philippines and describe their clinicodemographic profile, clinical presentation, imaging and ancillary diagnostic characteristics and outcome. Age range was from 35 to 64 years old. All three presented with dizziness and varying combinations of cranial nerve deficits, motor, sensory ataxia and cerebellar signs. Imaging modalities used are Magnetic Resonance Imaging (MRI) with time of flight (TOF) and computed tomography angiography (CTA). One had a left vertebral artery (VA) occlusion extending into the proximal basilar artery (BA). Another had a non-visualized right VA and bilateral posterior inferior cerebellar artery (PICA). The last case had an unremarkable vessel study. Treatment strategies include dual antiplatelet therapy (DAPT) with Aspirin and Cilostazol (2 of 3), and Enoxaparin plus Aspirin. One received intravenous thrombolysis with Alteplase prior to the DAPT. None were intubated and all were home discharged. Conclusion. We have shown that a bilateral medial medullary stroke can present with minimal disability and a good outcome.