A 69-year-old hypertensive male patient presented to an emergency unit with dysphonia, dysphagia and bilateral lower limb weakness of sudden onset, progressing to the upper limbs in 5 days. Head computed tomography did not show relevant findings. Initial diagnostic hypothesis was Guillain Barre syndrome. Cerebrospinal fluid analysis did not show abnormalities. He was then transferred to our unit for further investigation. Upon admission, significant weakness and spasticity were identified in all limbs, accompanied by altered deep sensation. Tongue mobility was limited. Severe dysphonia and dysphagia were present. Tendon reflexes were exacerbated, associated with bilateral Hoffmann’s and Babinski signs. Magnetic resonance imaging showed bilateral medial medullary lesions suggestive of infarction, with diffusion restriction. A possible cardioembolic origin was suggested by echocardiographic findings of enlarged left atrium with signs of blood stasis. He was discharged with regular speech and physical therapy sessions, and a prescription for anticoagulation with rivaroxaban and baclofen for symptomatic relief.

Bilateral medial medullary stroke is rare, and highly dependent on advanced neuroimaging resources as a diagnostic clue. Approximately 24% of patients will develop respiratory failure, contributing to worse prognosis. One-fifth of patients come to a fatal outcome, and two-thirds become dependent on others for daily activities.

Most common clinical presentations include motor weakness, dysarthria and hypoglossal palsy. Differential diagnoses include Guillain Barre syndrome and brainstem encephalitis.

Stroke mechanism varies from large vessel disease in 62% of cases, to small vessel disease in 28%, and cardiac embolism in a minority of cases.

Diagnosis of bilateral medial medullary stroke is a challenge. Misdiagnosis such as initially set for our patient is common and should be revisited to avoid unnecessary or harmful therapeutic strategies. Correct diagnosis is based on clinical suspicion plus MRI findings, and it is essential for adequate treatment implementation and further follow-up planning.