61-year-old female with no past medical history presented with acute onset paresthesia in left arm and leg. On presentation, her NIHSS was 0 but patient reported subjective left sided paresthesia. CT head was unremarkable and CT angiogram showed hypo plastic right vertebral artery with occlusion at V4 segment. She was not a candidate for acute thrombolytic therapy or endovascular thrombectomy due to low NIH. Overnight patient’s symptoms worsen to NIH 8 with left side drift and decreased sensation on the left. MRI brain showed acute infarct in right paramedian medulla. Two days after presentation, patient had weakness on the right side resulting in quadriplegia along with dysarthria and dysphagia.  Repeat MRI brain 4 days later showed acute infarct in left paramedian medulla as well resulting in “heart- shaped infarct” on imaging.  She was started on aspirin and Plavix. Upon discharge, patient had started to have some fine motor movement in left arm.

BMMS are very rare but are associated with a high degree of mortality and morbidity. The treatment for this is like other types of cerebral infarction. However, delays in diagnosis partly due to a limited understanding of the disease often leads to missing of the therapeutic window for thrombolysis. It requires high suspicion to diagnose BMMS early because of atypical clinical and radiological findings during initial stage of the disease. Diagnosing and initiating treatment early is imperative for a good prognosis. There is a need for more research in the development of more diagnostic tools to identify such strokes quickly and timely.