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1534 - Medial Medullary Syndrome in Hypertensive Emergency: A Rare Stroke Diagnosis Complicated By Health Disparities

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

TI

Tsunagu Ichikawa, BS

Medical Student
University of New England College of Osteopathic Medicine
Hudson, New York, United States

Co-Author(s)

MA

Michael O. Alen, MS

Medical Student
University of New England College of Osteopathic Medicine
Piscataway, New Jersey, United States
AS

Abhishek Shrinet, MD

Resident Physician
Temple University Hospital Physical Medicine and Rehabilitation
Philadelphia, Pennsylvania, United States
MW

Maitland B. Wiren, DO

Resident Physician
Temple University Hospital Physical Medicine and Rehabilitation
Philadelphia, Pennsylvania, United States

Case Diagnosis: Medial Medullary Syndrome in the Context of Hypertensive Emergency.

Case Description: A 51-year-old African American woman with untreated hypertension presented to the ED with hypertensive emergency and lightheadedness. She developed progressive left-sided weakness, paresthesias, left facial asymmetry, and right-sided tongue deviation. Initial head CT and CTA were unremarkable, and the MRI was interpreted as normal, leading to concerns of malingering. After a request to reread the MRI, she was diagnosed with medial medullary syndrome - a rare brain stem stroke. Her weakness rapidly progressed to spastic hemiplegia, necessitating baclofen for tone reduction and standard stroke management, followed by acute inpatient rehabilitation.

Discussions: African American women have disproportionately high rates of hypertension and cardiovascular disease, yet systemic barriers, like lack of insurance, limit access to preventive care. The rare location of her stroke contributed to a misinterpretation of the MRI and skepticism of her symptoms, delaying diagnosis and treatment. Her presentation was classic for medial medullary (Dejerine) syndrome, characterized by contralateral hemiplegia, epicritic sensation loss, and ipsilateral tongue deviation due to corticospinal, medial lemniscus, and hypoglossal nerve damage. This stroke type, caused by occlusion of paramedian branches of the anterior spinal, vertebral, or the basilar arteries, accounts for only 1% of all cerebral infarctions. Untreated hypertension, diabetes, and smoking are common risk factors, with severe hemiplegia often conferring a poor prognosis. Early rehabilitation, along with dysphagia and speech evaluation, is beneficial.

Conclusions: Medial medullary syndrome is a rare and debilitating brain stem stroke and can be easily overlooked on advanced imaging. In this underprivileged patient, its rarity contributed to delayed diagnosis and treatment. Greater sensitivity to social determinants of health, like medication access, and a commitment to eliminating diagnostic biases are essential for high-quality care. Early and accurate diagnosis, coupled with culturally competent care, can improve outcomes for underserved patients.