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NEUROIMAGES
Year : 2016  |  Volume : 64  |  Issue : 7  |  Page : 130

Bilateral medial medullary infarction with a "heart appearance" sign


1 Department of Family Medicine, Lakeshore Hospital and Research Centre, Ernakulam, Kerala, India
2 Department of Neurology, Lakeshore Hospital and Research Centre, Ernakulam, Kerala, India

Date of Web Publication3-Mar-2016

Correspondence Address:
Muhammed Jasim Abdul Jalal
Department of Family Medicine, Lakeshore Hospital and Research Centre, Nettoor. P.O., Maradu, NH 47 - Byepass, Ernakulam - 682 040, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.178059

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How to cite this article:
Jalal MJ, Menon MK. Bilateral medial medullary infarction with a "heart appearance" sign. Neurol India 2016;64, Suppl S1:130

How to cite this URL:
Jalal MJ, Menon MK. Bilateral medial medullary infarction with a "heart appearance" sign. Neurol India [serial online] 2016 [cited 2019 Sep 16];64, Suppl S1:130. Available from: http://www.neurologyindia.com/text.asp?2016/64/7/130/178059


A 74-year-old Indian diabetic and hypertensive male patient presented with sudden onset vertigo, dysphonia and dysphagia along with quadriplegia. He had a horizontal nystagmus and left palatal palsy, and his tongue was deviated towards the right side. Motor examination revealed quadriplegia (upper limbs with grade 0 power and lower limbs with grade 1 power). All the deep tendon reflexes were brisk. He had bilateral extensor plantar response.

Magnetic resonance imaging (MRI) brain diffusion-weighted imaging at 3 T revealed a heart-shaped hyperintensity area (the typical "heart appearance" sign) on both sides in the ventral medulla [Figure 1]. No abnormal signal was observed in the same region by fluid-attenuated inversion recovery. On the basis of these findings, the patient was diagnosed to be having an acute bilateral medial medullary infarction (MMI), and was treated with antiplatelets and anticoagulants. Physiotherapy and rehabilitation were initiated.
Figure 1: Magnetic resonance imaging brain diffusion-weighted imaging at 3 T showing the typical "heart appearance" sign in bilateral ventral medulla

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MMI accounts for <1% of all cases of brain infarctions. [1] Bilateral MMI is a rare stroke syndrome. Patients with bilateral MMI syndrome often present with quadriparesis, bilateral loss of deep sensations, dysphagia and speech difficulties. [2] Brainstem encephalitis may show a similar bilateral medial medullary infarction. [3] Guillain-Barre's syndrome can present as bilateral medial medullary infarction. [3] "Heart appearance" on MRI is, however, a unique presentation of bilateral MMI. [4]

The medulla oblongata is divided into the antero-medial territory, antero-lateral territory, lateral territory, and posterior territory, according to its vascular supply. The "heart appearance" sign is considered to appear when the infarct occurs in the antero-medial and antero-lateral territories.

The overall outcome of this type of stroke is not good and it is associated with severe morbidity and mortality. An early diagnosis based on the combination of clinical and MRI findings is, therefore, critical. Diagnosis of bilateral MMI has become easily possible with the advent of diffusion-weighted MRI.

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bassetti C, Bogousslavsky J, Mattle H, Bernasconi A. Medial medullary stroke: Report of seven patients and review of the literature. Neurology 1997;48:882-90.  Back to cited text no. 1
    
2.
Jagiella WM, Sung JH. Bilateral infarction of the medullary pyramids in humans. Neurology 1989;39:21-4.  Back to cited text no. 2
    
3.
Ma L, Deng Y, Wang J, Du F, Xia F, Liu Y, et al. Bilateral medial medullary infarction presenting as Guillain-Barré-like syndrome. Clin Neurol Neurosurg 2011;113:589-91.  Back to cited text no. 3
    
4.
Tokuoka K, Yuasa N, Ishikawa T, Takahashi M, Mandokoro H, Kitagawa Y, et al. A case of bilateral medial medullary infarction presenting with "heart appearance" sign. Tokai J Exp Clin Med 2007;32:99-102.  Back to cited text no. 4
    


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