Asian Journal of Research and Reports in Neurology

Bilateral medial medullary infarction is a rare and potentially devastating posterior circulation stroke that may be missed in its earliest stages because initial symptoms can be nonspecific and computed tomography‑based imaging may be unrevealing. We report the case of a 65‑year‑old man with hypertension, type 2 diabetes mellitus, and dyslipidaemia who presented within one hour of symptom onset with left‑sided weakness, facial deviation, and dysarthria. Initial non‑contrast computed tomography, computed tomography angiography, and computed tomography perfusion were unremarkable, and his deficits transiently improved. Over the ensuing hours, however, he developed progressive symmetrical weakness, worsening bulbar dysfunction, and abrupt deterioration to quadriplegia and aphonia. Repeat computed tomography remained non‑diagnostic. Magnetic resonance imaging performed the following morning demonstrated bilateral diffusion restriction within the ventral, middle, and dorsal medulla, with the characteristic heart‑shaped “Airpod sign” on axial diffusion‑weighted imaging. Magnetic resonance angiography showed diffuse severe atherosclerotic disease affecting both vertebral arteries and the proximal basilar artery. The patient was managed with antiplatelet therapy, anticoagulation, supportive care, permissive hypertension, metabolic stabilization, and respiratory support, then transferred for long‑term rehabilitation. This case highlights the progressive nature of bilateral medial medullary infarction, the limitations of early computed tomography in posterior circulation stroke, and the diagnostic importance of timely magnetic resonance imaging when medullary infarction is clinically suspected.