Hemiplegia Without a Lesion, Look Again: Vertebral Artery Compression of the Medulla as a Cause of Chronic Hemiplegia
Ampuriire Nyakubaho, Allan Bakesiga, Monica Acen Okwir, Brendah Ayikoru, Juliet Nyakake, James SenogaABSTRACT
Background
Vertebral Artery Compression Syndrome (VAMCS) is a rare but increasingly recognized vascular compression disorder of the medulla oblongata, most commonly presenting with paroxysmal symptoms such as hemi‐facial spasm, vertigo, or dysphagia. Longstanding, fixed hemiplegia is an atypical presentation that poses a significant diagnostic challenge.
Case Presentation
We report a case of a 29‐year‐old male with a longstanding history of left hemiplegia, initially presumed to be of cerebral origin. Non‐contrasted brain and spine MRI was performed. The spine MRI was essentially normal, showing only a loss of cervical lordosis. However, dedicated brain MRI with vascular assessment revealed a dilated and tortuous left vertebral artery compressing the left part of the distal medulla that ascended and looped medially, crossing the midline to compress and flatten the right part of the rostral medulla oblongata, approximately 1.5 cm cranial to the foramen magnum.
Discussion
This case highlights a crucial radiological tenet: a normal spine MRI does not exclude an intracranial vascular cause for myelopathy‐like symptoms. The distal medulla houses the decussation of the cortico‐spinal tracts. Chronic, fixed compression above this level can mimic a cervical myelopathy or a brainstem infarct, leading to a longstanding contralateral hemiparesis.
Conclusion
VAMCS should be considered in the differential diagnosis of young patients with unexplained, longstanding hemiplegia, especially when conventional spine imaging and cerebral imaging is unremarkable. Radiologists must actively evaluate the vertebrobasilar system and its relationship to the medulla in such cases, as the finding directly impacts clinical management and surgical planning.