INTRODUCTION 
Medial medullary infarcts are rare and represents less than 1% of posterior circulation strokes. We present a case which posed significant diagnostic challenge both clinically and radiologically mainly due to the bilateral anatomical involvement. 

METHOD
Case report

DISCUSSION
A 65 year-old gentleman with history of atrial fibrillation and hypertension experienced an acute reduction in visual acuity and altered sensation of all four limbs. He presented to the emergency department the following day after developing dizziness and ataxia. Past pointing and intention tremor were seen in the left upper limb. Initial CT head scan only showed an old established infarct, and MRI brain was reported normal. Over the next 24 hours he developed progressive weakness of limb and bulbar muscles necessitating intubation. Guillain-Barre Syndrome was suspected and intravenous immunoglobulins administered. No improvement was noted and a lumbar puncture was inconclusive. Subsequent MRI brain and cervical spine scans showed acute bilateral medial medullary infarction along the vascular territory of the anterior spinal artery which was not obvious in the initial MRI scan. He was started on anti-platelet treatment and made slow recovery. He was extubated but required a long-term tracheostomy

CONCLUSION
Bilateral infarctions in the medial medulla are very rare and may present with varied clinical features. Extensive literature review showed only one previous case report of medial medially syndrome clinically mimicking a peripheral polyneuropathy. This case is being presented for the rarity of the condition and also to highlight the diagnostic challenges it can pose.

A CASE OF ACUTE BILATERAL MEDIAL MEDULLARY INFARCTION