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Published in: Neurocritical Care 3/2018

01-06-2018 | Practical Pearl

Heart-Shaped Bilateral Medullary Pyramidal Infarction as a Pathognomonic Finding of Anterior Spinal Artery Occlusion

Authors: Sammy Searcy, Oluwaseun O. Akinduro, Andrew Spector, Jang W. Yoon, Benjamin L. Brown, William D. Freeman

Published in: Neurocritical Care | Issue 3/2018

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Abstract

Background

Unilateral anterior spinal artery (ASA) occlusion resulting in bilateral medullary pyramidal (BMP) infarction is a rare and devastating stroke subtype. We present two cases highlighting the diagnostic and clinical challenges of BMP infarction.

Methods

Case reports and literature review.

Results

A 57-year-old man rapidly had severe vomiting and diarrhea 2 h after a meal. Examination revealed bulbar weakness and areflexic tetraplegia. Respiratory failure developed, requiring intubation and mechanical ventilation. Brain magnetic resonance imaging (MRI) showed a heart-shaped region of diffusion abnormality, characteristic of BMP infarction. Cerebral angiography showed an occluded left vertebral artery with unilateral left-sided origin of ASA. The patient required tracheostomy and percutaneous gastrostomy tube and was discharged to rehabilitation, with little improvement of his tetraplegia at 3-month follow-up.
A 43-year-old woman presented to the emergency department with acute onset of lower-extremity paresthesia and history of upper respiratory infection 2 weeks prior. Initial examination findings included bulbar weakness, dysphagia, hyporeflexia, and generalized weakness. After admission, she had severe respiratory distress and required intubation. Lumbar puncture was evaluated for Guillain–Barré syndrome, but cerebrospinal fluid protein concentration was normal. Changes on diffusion-weighted MRI of the brain showed the characteristic heart-shaped BMP infarction, indicating occlusion of a unilateral ASA. She required tracheostomy and percutaneous gastrostomy tube placement, with no paralysis resolution.

Conclusion

Acute BMP infarction may present with flaccid tetraplegia mimicking neuromuscular disorders. When the infarction is recognized early, intravenous thrombolysis can be considered to reduce morbidity of this rare stroke subtype.
Literature
1.
go back to reference Pongmoragot J, Parthasarathy S, Selchen D, Saposnik G. Bilateral medial medullary infarction: a systematic review. J Stroke Cerebrovasc Dis. 2013;22(6):775–80.CrossRefPubMed Pongmoragot J, Parthasarathy S, Selchen D, Saposnik G. Bilateral medial medullary infarction: a systematic review. J Stroke Cerebrovasc Dis. 2013;22(6):775–80.CrossRefPubMed
2.
go back to reference Kumral E, Afsar N, Kirbas D, Balkir K, Ozdemirkiran T. Spectrum of medial medullary infarction: clinical and magnetic resonance imaging findings. J Neurol. 2002;249(1):85–93.CrossRefPubMed Kumral E, Afsar N, Kirbas D, Balkir K, Ozdemirkiran T. Spectrum of medial medullary infarction: clinical and magnetic resonance imaging findings. J Neurol. 2002;249(1):85–93.CrossRefPubMed
3.
go back to reference 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(3):99–102.PubMed 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(3):99–102.PubMed
4.
go back to reference Milandre L, Martini P, Bourrin JC, Vincentelli F, Khalil R. Unilateral infarction of the cervical spinal cord. 2 cases identified by MRI. Rev Neurol (Paris). 1993;149(4):299–302 (French).PubMed Milandre L, Martini P, Bourrin JC, Vincentelli F, Khalil R. Unilateral infarction of the cervical spinal cord. 2 cases identified by MRI. Rev Neurol (Paris). 1993;149(4):299–302 (French).PubMed
5.
go back to reference Yuki N, Hartung HP. Guillain–Barré syndrome. N Engl J Med. 2012;366(24):2294–304. Erratum in: N Engl J Med. 2012;367(17):1673. Yuki N, Hartung HP. Guillain–Barré syndrome. N Engl J Med. 2012;366(24):2294–304. Erratum in: N Engl J Med. 2012;367(17):1673.
6.
go back to reference Brannagan TH 3rd, Zhou Y. HIV-associated Guillain–Barré syndrome. J Neurol Sci. 2003;208(1–2):39–42.CrossRefPubMed Brannagan TH 3rd, Zhou Y. HIV-associated Guillain–Barré syndrome. J Neurol Sci. 2003;208(1–2):39–42.CrossRefPubMed
7.
go back to reference Tam CC, O’Brien SJ, Petersen I, Islam A, Hayward A, Rodrigues LC. Guillain–Barré syndrome and preceding infection with campylobacter, influenza and Epstein–Barr virus in the general practice research database. PLoS ONE. 2007;2(4):e344.CrossRefPubMedPubMedCentral Tam CC, O’Brien SJ, Petersen I, Islam A, Hayward A, Rodrigues LC. Guillain–Barré syndrome and preceding infection with campylobacter, influenza and Epstein–Barr virus in the general practice research database. PLoS ONE. 2007;2(4):e344.CrossRefPubMedPubMedCentral
8.
go back to reference Yiannakopoulou E. Serious and long-term adverse events associated with the therapeutic and cosmetic use of botulinum toxin. Pharmacology. 2015;95(1–2):65–9.CrossRefPubMed Yiannakopoulou E. Serious and long-term adverse events associated with the therapeutic and cosmetic use of botulinum toxin. Pharmacology. 2015;95(1–2):65–9.CrossRefPubMed
9.
go back to reference Diaz-Manera J, Rojas Garcia R, Illa I. Treatment strategies for myasthenia gravis: an update. Expert Opin Pharmacother. 2012;13(13):1873–83.CrossRefPubMed Diaz-Manera J, Rojas Garcia R, Illa I. Treatment strategies for myasthenia gravis: an update. Expert Opin Pharmacother. 2012;13(13):1873–83.CrossRefPubMed
10.
11.
go back to reference 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(7):589–91.CrossRefPubMed 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(7):589–91.CrossRefPubMed
13.
go back to reference Roh JK, Lee YS. Bilateral medial medullary infarction manifested as sensory ataxia: a case report and review of the literature. J Korean Med Sci. 1996;11(2):193–6.CrossRefPubMedPubMedCentral Roh JK, Lee YS. Bilateral medial medullary infarction manifested as sensory ataxia: a case report and review of the literature. J Korean Med Sci. 1996;11(2):193–6.CrossRefPubMedPubMedCentral
14.
go back to reference Santos-Franco JA, de Oliveira E, Mercado R, Ortiz-Velazquez RI, Revuelta-Gutierrez R, Gomez-Llata S. Microsurgical considerations of the anterior spinal and the anterior-ventral spinal arteries. Acta Neurochir (Wien). 2006;148(3):329–38.CrossRef Santos-Franco JA, de Oliveira E, Mercado R, Ortiz-Velazquez RI, Revuelta-Gutierrez R, Gomez-Llata S. Microsurgical considerations of the anterior spinal and the anterior-ventral spinal arteries. Acta Neurochir (Wien). 2006;148(3):329–38.CrossRef
15.
go back to reference Gofton TE, Barber PA. Anterior spinal artery infarction at the cervicomedullary junction. Can J Neurol Sci. 2006;33(4):418–20.CrossRefPubMed Gofton TE, Barber PA. Anterior spinal artery infarction at the cervicomedullary junction. Can J Neurol Sci. 2006;33(4):418–20.CrossRefPubMed
16.
go back to reference Machnowska M, Moien-Afshari F, Voll C, Wiebe S. Partial anterior cervical cord infarction following vertebral artery dissection. Can J Neurol Sci. 2008;35(5):674–7.CrossRefPubMed Machnowska M, Moien-Afshari F, Voll C, Wiebe S. Partial anterior cervical cord infarction following vertebral artery dissection. Can J Neurol Sci. 2008;35(5):674–7.CrossRefPubMed
17.
go back to reference Hundsberger T, Thomke F, Hopf HC, Fitzek C. Symmetrical infarction of the cervical spinal cord due to spontaneous bilateral vertebral artery dissection. Stroke. 1998;29(8):1742.CrossRefPubMed Hundsberger T, Thomke F, Hopf HC, Fitzek C. Symmetrical infarction of the cervical spinal cord due to spontaneous bilateral vertebral artery dissection. Stroke. 1998;29(8):1742.CrossRefPubMed
18.
go back to reference Andreoli L, Chighizola CB, Banzato A, Pons-Estel GJ, Ramire de Jesus G, Erkan D. Estimated frequency of antiphospholipid antibodies in patients with pregnancy morbidity, stroke, myocardial infarction, and deep vein thrombosis: a critical review of the literature. Arthritis Care Res (Hoboken). 2013;65(11):1869–73.CrossRef Andreoli L, Chighizola CB, Banzato A, Pons-Estel GJ, Ramire de Jesus G, Erkan D. Estimated frequency of antiphospholipid antibodies in patients with pregnancy morbidity, stroke, myocardial infarction, and deep vein thrombosis: a critical review of the literature. Arthritis Care Res (Hoboken). 2013;65(11):1869–73.CrossRef
Metadata
Title
Heart-Shaped Bilateral Medullary Pyramidal Infarction as a Pathognomonic Finding of Anterior Spinal Artery Occlusion
Authors
Sammy Searcy
Oluwaseun O. Akinduro
Andrew Spector
Jang W. Yoon
Benjamin L. Brown
William D. Freeman
Publication date
01-06-2018
Publisher
Springer US
Published in
Neurocritical Care / Issue 3/2018
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-017-0406-7

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