The co-occurrence of bilateral medial medullary infarction and anterior spinal artery syndrome in pregnancy: A case report

Abstract

Anterior spinal artery occlusion resulting in bilateral medial medullary infarction (bMMI) and anterior spinal artery syndrome (ASAS) simultaneously has been rarely described. To the best of our knowledge, this is the first report of such occurrence during pregnancy. A 23-year-old preeclamptic parturient at 374/7 weeks underwent an emergent cesarean section after developing gradual neurological deficits. Her symptoms started with a severe occipital headache and progressed to right-hand tingling, left-hand weakness, dyspnea, and elevated blood pressure (165/117 mmHg). Spinal anesthesia was performed by injection of bupivacaine 0.5% with no complications. Twenty minutes into the surgery, after the patient's systolic pressure fell below 85 mmHg, a bolus dose of ephedrine was administered. After a while, the patient presented with sudden respiratory distress and declining consciousness, prompting her immediate intubation. In the intensive care unit, she initially exhibited flaccid quadriplegia, sensory loss, areflexia, upward vertical nystagmus, and some cranial nerve (CN) palsy, including CN 9, 10, and 12, indicative of a medullary-level infarction extending downward. The magnetic resonance imaging (MRI) of the brain revealed a heart-shaped sign in the medulla, suggesting bMMI as a result of anterior spinal artery (ASA) occlusion. During the course of hospitalization, the patient regained the senses of vibration, touch, and proprioception; however, she has remained quadriplegic up to now.

Keywords

• Anterior spinal artery
• Medullary infarction
• Quadriplegia
• Pregnancy
• Hypertension
• Spinal anesthesia