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Bilateral infarction of the medullary pyramids

Drs. Jagiella and Sung' reported a clinicopathologic case of brainstem paramedian infarction restricted to both medullary pyramids. We observed a similar case with very early spasticity. Case report. A 63-year-old man with a history of hypercholesterolemia was admitted with quadriparesis that had gradually developed over 4 days, in association with dysphagia, dysphonia, and urinary retention. At examination, he was fully alert and oriented. He had a severe quadriparesis, worse on the left side. The tendon reflexes were brisk without clonus, and a Babinski's sign was noted bilaterally. There was slightly increased tone in the arms and increased stretch reflex in the legs. Gag and cough reflexes were decreased, as was palatal elevation. There was no volitional movement in the trapezius muscles. Tongue protrusion, sensory, and upper cranial nerves examinations were normal. CSF examination and CT findings were unremarkable. After he was placed on heparin, his clinical status improved slightly with decrease in the right side weakness. Two months after onset, he was discharged to a rehabilitation center with a nasogastric feeding tube and a urinary catheter. He was readmitted 1 month later because of renal failure. Strength was 3/5 on the right side and 1/5 on the left side. Spasticity had increased and was more marked in lower limbs. Ankle clonus and a triple flexion response were noted. He died after several days from aspiration pneumonia. At autopsy, the pertinent findings in the gross examination of the brain consisted of severe atherosclerosis of the major intracranial arteries and bilateral infarction of the pyramids on transverse sections of the medulla. Myelin staining showed a near-total demyelination of the right medullary pyramid. The left pyramid showed discoloration and an area of cuneiform necrosis (figure). Microscopic sections revealed severe myelin swelling in the left pyramid, and numerous lipid-laden phagocytes were seen within the cystic necrotic area of the right pyramid. The medial accessory olive was affected on the left side. The remaining structures of the medulla were spared.