Case

A woman in her 50s with hypertension presented with acute right hemiparesis of the arm and leg with a National Institutes of Health Stroke Scale score of 11. CT cerebral angiography was normal, with a dominant right vertebral artery (figure 1A). Initial MR scan of brain showed subtle ischaemic changes in the medulla (figure 1B). She had presented out of the acute thrombolysis window and so received anti-platelet and statin therapy. Twelve hours after onset, she developed acute left hemiparesis and bulbar weakness requiring intubation and mechanical ventilation. Subsequent MR scan of brain 4 days later showed the ‘heart-shaped’ sign of bilateral medial medullary …