Abstract
Posterior circulation strokes can present with diverse neurological deficits, some of which challenge conventional localization principles. We report a case of a 74-year-old male with a history of prior right medullary infarct who presented with recurrent symptoms and was found to have a new medullary acute ischemic stroke in the setting of chronic right vertebral artery occlusion. Notably, the patient exhibited ipsilateral limb weakness, a finding attributable to involvement near the pyramidal decussation at the medulla-spinal cord junction. This case underscores the importance of detailed neuroanatomical understanding in vertebrobasilar ischemia and highlights the diagnostic complexity of brainstem strokes.