• Heart appearance sign
• bilateral medial medullary infarction
• adult neurology
• neuroradiology
• stroke medicine

A 70-year-old man with hypertension and diabetes mellitus had an episode of giddiness followed by numbness and mild weakness of the right upper and lower limbs. He woke up the next morning with weakness of all four limbs and slurred speech and was admitted to hospital. On admission, he had severe tongue weakness and flaccid quadriparesis with upgoing plantars. He also had horizontal nystagmus to both directions. Within a few hours of admission, he developed respiratory distress and required ventilator support. MRI of the brain revealed bilateral medial medullary hyperintensities in theT2-weighted and fluid attenuated inversion recovery sequences and showed restricted diffusion (figure 1). The lesion had the characteristic ‘heart appearance’ on axial MR images described in bilateral medial medullary infarction (MMI).1 MR angiography showed features of atherosclerotic disease of the bilateral vertebral and basilar arteries. Electrocardiogram and transthoracic echocardiogram were within normal limits. …