Teaching NeuroImage: Reinhold Hemimedullary Syndrome

A 32-year-old man without vascular risk factors presented with acute onset vertigo, swallowing dysfunction, and right-sided weakness. Physical examination revealed the following signs on the left side: Horner syndrome; lower motor neuron 9th, 10th, and 12th cranial nerve palsies; cerebellar limb ataxia; loss of pain and temperature on the face; and loss of fine touch and proprioception on the face, trunk, and limbs. On the right side, he had hemiplegia with loss of pain and temperature on the trunk and limbs. Brain MRI revealed acute infarct involving the left half of the medulla (Figure, A and B). CT angiogram of the head and neck vessels showed occlusion of the left vertebral artery V4 segment (Figure, C, D, and E). A diagnosis of Reinhold complete hemimedullary syndrome was made (Table).1-3 The almost similar incomplete hemimedullary syndrome of Babinski-Nageotte lacks ipsilateral hypoglossal nerve palsy.2 Workup for stroke etiology revealed normal glycosylated hemoglobin, lipid profile, and negative hypercoagulable, autoimmune, and vasculitis panels. Echocardiogram was normal with prolonged cardiac telemetry revealing no cardiac arrhythmias. He was maintained on acetylsalicylic acid 100 mg once daily and atorvastatin 40 mg at nighttime for secondary stroke prophylaxis.