Acute quadriparesis:gbs or bilateral medullary infarct – a neurologist’s dilemma

Bilateral medial medullary stroke is a very rare type of stroke, with catastrophic consequences. Early diagnosis is crucial. Here, we report a case presenting with acute vertigo, progressive generalized weakness of all 4 limbs, dysarthria, and decreased single breath count. Brain magnetic resonance imaging (MRI) that was done showed characteristic “heart appearance” shape at diffusion weighted (DWI), and confirmed bilateral medial medullary stroke. Other possibilities were excluded by lumbar puncture and MRI of cervical spine with screening of whole spine. Retrospectively, a vague-defined hyperintense linearDWI signal at midline was noted in the first brain MRI. Because of the symmetric and midline pattern of this abnormal signal and similarityto an artifact, some radiologists or neurologists may miss this type of stroke. Radiologists and neurologists must co relate clinical and MRI findings of this rare type of stroke, where early treatment could make a difference in patient outcome and therapy. The abnormal DWIsignal in early stages of this type of stroke may not be a typical “heart appearance” shape, and other variants such as small dot or linear DWI signal at midline must be recognized as early signs of stroke. Also, MRI of cervical spine may be helpful if there is suspicion of spinal pathology.