From locked-in syndrome to recovery: thrombolysis success in bilateral pontine infarction with ‘heart appearance’ sign

Locked-in syndrome (LIS) is a severe neurological condition characterised by tetraplegia and anarthria, with preserved consciousness and vertical eye movements. It often results from bilateral pontine infarctions, which sometimes demonstrate a characteristic 'heart appearance' sign on MRI. We report a case of a mid-60s female with acute onset LIS and dyspnoea. Clinical examination suggested a pontine infarction, later confirmed by an MRI scan revealing a characteristic 'heart appearance' on axial diffusion-weighted imaging sequence. As the patient presented within the thrombolysis time window and had no contraindications, alteplase was administered. The patient demonstrated an exceptional neurological improvement within 10 days of hospitalisation, transitioning from tetraplegia and anarthria to moving all four limbs against gravity and mild dysarthria. She was subsequently discharged to a rehabilitation centre. This case underscores the efficacy of timely thrombolysis in severe pontine strokes and highlights the diagnostic significance of MRI findings in such cases.