Reverse 'hot cross bun', 'Mercedes-Benz', 'face of the giant panda and her cub' signs with pontine infarcts: a radiological pandora.

To cite: Jain RS, Sannegowda RB, Jain R, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013203447 DESCRIPTION Though uncommon, bilateral middle cerebellar peduncle (MCP) hyperintensities have been reported following pontine infarcts, in Wilson disease (WD) and due to other aetiologies. In WD, the ‘face of the giant panda’ sign, internal capsule hyperintensities and rarely the ‘face of the panda cub’ sign due to pontine hyperintensities at the opening of the cerebral aqueduct into the fourth ventricle is described. The ‘hot cross bun’ (HCB) sign is seen in multisystem atrophy, spinocerebellar ataxia and rarely in cerebrotendinous xanthomatosis. We report a case of a hypertensive man with recurrent, sudden onset, cranial nerve palsies (third and lower motor neuron seventh nerves) followed by complete recovery without any cognitive or movement disorder manifestations. Workup for the WD and vasculitis was negative. CT angiography of the brain, including neck vessels, was normal. MRI of the brain showed bilateral MCP hyperintensities with pontine infarcts (figure 1A). Interestingly, MRI also showed multiple radiological signs. Though the HCB sign is described due to cruciform hyperintensity in the pons resulting from the degeneration of pontine neurons and loss of myelinated transverse fibres with preserved tegmentum and corticospinal tracts, in our patient there was cruciform hypointensity quadrisecting the pontine hyperintensities to suggest a reverse HCB sign (figure 1B) along with bilateral internal capsule hyperintensities (figure 1C). Our patient also had a ‘face of the