Objective:

To report a rare case of a 59-year-old male with bilateral medial medullary strokes leading to quadriplegia and bulbar dysfunction secondary to amphetamine abuse. 

Background:

< 1.5% of posterior circulation ischemic strokes are medullary strokes. Bilateral medial medullary strokes are extensively rare and are known to be caused by atherothrombotic occlusion of paramedian branches of the anterior spinal artery, the vertebral artery, or the basilar artery. Mortality rate is  ~25%, while 2/3rd of survived remain dependent.  

Design/Methods:

Case report with electronic medical chart review. 

Results:

59-year-old male with past medical history of Hepatitis-B, Diabetes mellitus-2 and drug abuse presented with bilateral extremities paresthesias and weakness graded as 4/5, dysarthria, and dizziness. Patient initial MRI brain and CTA head and neck were unremarkable for any infarct or flow limiting stenosis, respectively. He tested positive for amphetamines in urine. Next day the patient developed worsening weakness bilaterally, prompting a repeat MRI Brain W WO, which showed bilateral medial medullary infarcts. Patient through the day transitioned to quadriplegia with only extraocular movements intact. The patient was intubated due to respiratory distress. Transesophageal echocardiography (TEE) revealed normal left atrial size and left ventricle ejection fraction of 60 % with no thrombus in any chamber. On day 4 he tolerated CPAP with appropriate negative inspiratory flow and weak cough reflex. The patient was extubated, however shortly afterwards, he showed fatigue with labored breathing and weak and inadequate secretion clearance with signs of early stridor. The patient was reintubated and eventually on Day 10th the patient was transitioned to tracheostomy tube. Patient unfortunately remains quadriplegic

Conclusions:

Bilateral medial medullary strokes are rare with poor functional outcome. Clinical exams are of the essence in such patients as brainstem strokes initially might not be visualized on MRI, mimicking neuromuscular disorders, and can progress quickly to respiratory insufficiency requiring ventilator support.