Objective:

Background:

Bilateral MMI is a rare type of stroke typically presenting with flaccid or spastic quadriparesis, dysarthria, and hypoglossal nerve palsy. GBS can present with similar symptoms. Early recognition is crucial for timely management.

Design/Methods:

NA

Results:

A 55-year-old male with a past medical history of hypertension, hyperlipidemia, diabetes mellitus, and coronary artery disease presented with rapidly progressive ascending weakness and numbness in all four extremities over two days. Exam showed asymmetrical flaccid quadriparesis (right more than left) with normal reflexes and impaired sensory modalities, mild dysarthria, and dysphagia. Given the ascending weakness, GBS was considered. Cerebrospinal fluid was unremarkable except for elevated protein (60 mg/dL). Magnetic resonance imaging subsequently showed bilateral MMI with a classic “airpod” or “heart” sign. CT angiogram of the head showed abrupt change in caliber of a proximally prominent right posterior inferior cerebellar artery with diffusely decreased caliber distally. Digital subtraction angiography did not reveal significant large vessel disease. The patient was treated with dual antiplatelet therapy. With physical therapy, his strength significantly improved over the two-week hospital course and he could ambulate with a rolling walker upon discharge.

Conclusions:

Bilateral MMI is very rare and can present with flaccid paralysis in the early phase, which can be mistaken for GBS. Physicians must maintain a high level of clinical suspicion for bilateral MMI in patients with initial symmetric flaccid weakness and recognize that lingual paresis is frequently absent in bilateral MMI. Patients must undergo thorough, repeated physical examinations for assessment of tone and deep tendon reflexes. Despite the common belief that bilateral MMI has a poor prognosis, our patient achieved a good outcome with significant improvement following supportive care.