Heart in the Brain

A 52-year-old man with a 5-year history of diabetes mellitus and chronic renal disease presented with sudden onset left upper limb weakness and numbness at 5 pm, which progressed to quadriplegia by the next day at 2:30 am. He had dysarthria at admission. There were no sensory symptoms in the lower limbs. There were no bladder symptoms. Examination showed bilateral tongue weakness and quadriplegia, with the left side more affected than the right. Reflexes were sluggish bilaterally. Plantars were extensor bilaterally. The sensory system was normal in all four limbs, including joint position sense and vibration. Diffusion-weighted magnetic resonance imaging (MRI) of the brain showed diffusion restriction in the bilateral medial medulla simulating a heart sign, suggestive of a bilateral medial medullary infarct (Figs 1 and 2). MR angiography showed left vertebral artery stenosis. He was treated as per stroke protocol and made partial recovery at follow-up.