Journal of
eISSN: 2373-6410
Submit manuscript...
Case Report Volume 10 Issue 2
Triplegia due to right vertebral artery thrombosis: anterior medullary tia or stroke? A case report
Mariella Baldini,1 
Verify Captcha
Regret for the inconvenience: we are taking measures to prevent fraudulent form submissions by extractors and page crawlers. Please type the correct Captcha word to see email ID.
Elisa Grifoni,2 Michele Testaferrata,3 Paola Bartalucci,3 Massimo Armellani,4 Simone Vanni,3 Luca Masotti,2 Leonello Guidi1
Verify Captcha
Regret for the inconvenience: we are taking measures to prevent fraudulent form submissions by extractors and page crawlers. Please type the correct Captcha word to see email ID.
1Neurology, San Giuseppe Hospital, Empoli, Italy
2Internal Medicine II and Stroke Unit, San Giuseppe Hospital, Empoli, Italy
3Department of Emergency, San Giuseppe Hospital, Empoli, Italy
4Radiology, San Giuseppe Hospital, Italy
Correspondence: Mariella Baldini, Neurologist in Neurology of S. Giuseppe Hospital, viale Boccaccio Empoli, Florence, Italy, Tel +393470460293
Received: February 01, 2020 | Published: April 6, 2020
Citation: Baldini M, Grifoni E, Testaferrata M, et al. Triplegia due to right vertebral artery thrombosis: anterior medullary tia or stroke? A case report. J Neurol Stroke. 2020;10(2):67-68. DOI: 10.15406/jnsk.2020.10.00413
Abstract
Anterior medullary syndrome is a rare type of stroke due to theocclusion of the anterior spinal artery or vertebral artery or its branches. Here, we report the case of a 65-year old female with a clinical presentation of triplegia, caused by unilateral right proximal vertebral artery (VA) thrombosis, treated with intravenous thrombolysis in the Emergency Room. No diffusion-weighted imaging (DWI) magnetic resonance (MR) lesions were detected. Was it a transient ischemic attack (TIA) or a stroke of medullary pyramid?
Keywords: vertebral artery ischemia, anterior medullary syndromes, transient ischemic attack, posterior circulation
Abbreviations
ASA, anterior spinal artery; PICA, posterior inferior cerebellar artery; VA, vertebral artery; DWI, diffusionweighted imaging; MR, magnetic resonance; CT, computed tomography
Introduction
The medulla oblongata can be divided into four 4 zones according to its arterial circulation: the medianzone, whichis perfused bythe anterior spinal artery (ASA) at the level of lower medulla and the upper bulbar branches at the level of upper medulla, the paramedian zone, perfused by ASA, posterior inferior cerebellar artery (PICA) and the middle bulbar branches, the lateral zone,perfused by PICA and lower bulbar branches, and the dorsal zone,perfused byPICA and posterior spinal artery. Dissection or thrombosis of the vertebral artery (VA) may involve ASA, PICA, and multiple bulbar branches, causing infarctions in both the medial and lateral medulla, although such infarctions due to failure of the VAhave not been reported yet in detail.1,2
Here, we describe thecase of a 65-year old female with triplegia caused by unilateral right VA thrombosis. No diffusion-weighted imaging (DWI) magnetic resonance (MR) lesions were detected. Was it a transient ischemic attack (TIA) or a stroke of the anterior region of medulla oblongata?
Case report
We report the case of a 65-year old housewife, with risk factors for atherosclerosis, including hypertension and hyperlipidemia,who had in her history one episode of paraplegia lasting 24 hours. Six months later she came to medical attentiontothe Emergency Department for sudden development of weakness of theright leg, which resolved completely within one hour. Subsequently, she suddenly developed a triplegia (right hemiparesis and paresis of left leg, with bilateral Babinski sign, NIHSS 3). Brain computed tomography (CT) with vascular study of extra- and intracranial vessels was performed. Brain CT was normal, but the vascular study showed proximal thrombosis of right VA (Figure1). She was treated with intravenous thrombolysisafter20 minutes fromthe onsetof symptoms. At the end of the treatment the neurological examination was normal (NIHSS 0 and no Babinski sign). Thereafter, the patient was admitted to the Stroke Unit, and underwent brain and cervical MR, which didn’t show any ischemic lesion on DWI-MR.She was treated with acetylsalicylic acid 300 mg and statin, and she was discharged. After 2 months transcranial duplex sonography showed flow signals and increased flow velocities in right VA V3segment (150 cm/sec of peak systolic flow velocity and IP 1.35), no flow in right VA V4 segment.3
After six months, brain CT with vascular study showed no changes compared to the previous one, confirmingthe proximal thrombosis of right VA. Then, the patient felt well, and no new ischemic event occurred.
Discussion
Infarction of anterior region of medulla oblongata is a rare condition with only pyramidal tract involvement. However, reviewing the literature, we found that the clinical features are variable in medullary stroke/TIA. In particular, Opalski syndrome is characterized by the presence of ipsilateral hemiplegia associated with symptoms of alateral medullary syndrome. Thus far, most of the reported cases of this syndrome have been attributed to VA occlusion/stenosis, or dissection, which compromises the medullary penetrating arteries. The pyramidal fibersinvolvement in Opalski syndrome areipsilateral to the side of the infarct, asthese fibersare after their crossing from contralateral side at the level of lower medulla. Diffusion-weighted imaging is a sensitive MR sequence to detect an acute infarct. However, according to the available literature, the detection of this infarct as cause of Opalski syndrome has been reportedonly twice before, and is extremely rare.4–7
Our patient presented with a neurological examination that revealed right-sided hemiparesis, left leg paresis and bilateral plantar reflex in extension.The brain CT examination with vascular study of extra- and intracranial vessels showed proximal thrombosis of right VA, and the patient was quickly treated with intravenous thrombolysis; therefore, no DWI-MRlesions were detected (Figure 1).
In case of chronic and slowly progressing occlusive processes, patients with VA stenosisdevelop collateral pathways (from anterior circulation via the posterior communicating artery -PCoA- or from the posterior circulation via ASA or from leptomeningeal arteries). However, often this is no sufficient, andmay lead to impaired perfusion in the dependent brain territories. If a completed stroke occurs, the infarct pattern depends on the site of the vascular pathology.8-9
This case report is of interest for two reasons. First, the patientsuddenly developed triplegia, and we suspected an hemimedullary infarct and contralateral medial medullary infarct (anterior medullar zone of pyramidal crossing), and this combination is rare. Second, the DWI-MR was normal after intravenous thrombolysis; thus,we can hypothesize an early revascularization, but also a TIA on a hemodynamic basis.10
Acknowledgments
None.
Conflicts of interest
The author declares no conflicts of interest.
References
- Valdueza JM, Schereiber SJ, Roehl JE, et al. Neurosonology and Neuroimaging of Stroke. Thieme, New York: Georg Thieme Verlag; 2008.
- Irie F, Toyoda K, Hagiwara N, et al. Babinski-Nageotte syndrome due to vertebral artery dissection. Internal Medicine. 2003;42(9):871–874.
- Liu CY, Chang PY, Hu HH, et al. Ipsilateral crural monoparesis in lateral medullary infarction due to vertebral artery dissection. Eur J Neurol. 2006;13(7): E8-E9.
- García-García J, Ayo-Martín O, Segura T. Lateral medullary syndrome and ipsilateral hemiplegia (Opalski syndrome) due to left vertebral artery dissection. Arch Neurol. 2009;66:1574–1575.
- Bailon O, Garcia PY, Logak M, et al. Opalski syn-drome detected on DWI MRI: a rare lateral medullary infarction. Case report and review. Rev Neurol (Paris).2011;167:177–180.
- Deshpande A, Shetty A, Pai AR, et al. Abnormal brain MRI diffusionweighted imaging in a case of Opalski syndrome. BMJ Case Report. 2014.
- Shin HK, Yoo KM, Chang HM, et al. Bilateral intracranial vertebral artery disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 1999;56(11):1353–1358.
- Terao S, Izumi M, Takatsu S, et al. Serial magnetic resonance imaging shows separate medial and lateral medullary infarctions resulting in the hemimedullary syndrome. J Neurol Neurosurg Psychiatry. 1998; 65(1):134–135.
- Gondim Fde A, Cruz-Flores S, Leacock RO. Neuroimaging and pathology of the progression of unilateral to bilateral medial medullary stroke. Cerebrovasc Dis. 2006; 22(2-3):202–204.
- Kang K, Lee JJ, Park JM, et al. Progression of Oplasky syndrome to the hemimedullary and contralateral medial medullary infarct. International J of Stroke. 2015;10:E3–E4.
©2020 Baldini, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.