A sequential bilateral medial medullary infarction separated by 4 months

Medial medullary infarcts (MMI) account for less than 0.5% of all cerebral infarcts.1 They may be unilateral or, rarely, bilateral.1,2⇓ Clinical recognition is often difficult, because most reported signs are also consistent with cerebral or pontine localization. We recently encountered a patient with sequential MMI who manifested classic clinical signs of MMI. Initially, she presented with unilateral MMI, which 4 months later became bilateral. An 81-year-old woman with long history of hypertension had a sudden onset of right hemiparesis on the day of admission. Examination showed a coarse nystagmus when she looked to her left, and right lower facial weakness with ipsilateral hemiparesis (III/V) accompanied by right-sided vibratory and proprioceptive loss. Mild dysarthria accompanied by a left tongue deviation was also present. MRI revealed a left rostral MMI extending from the ventral pyramid to the floor of the fourth ventricle (figure, A). MR …