Neuroscience · Year 2 · from Neuroscience
Case 2: Lateral Medullary (Wallenberg) Syndrome
Patient Presentation
Demographics: 54-year-old male
Chief Complaint: Sudden dizziness, difficulty swallowing, and "numbness on one side of face"
History of Present Illness: The patient was at work when he suddenly felt intense vertigo and nausea. He vomited twice. He noticed his voice sounded hoarse and had difficulty swallowing water. He also felt that the left side of his face was numb and that objects seemed to be tilting to the left. He has a history of hypertension and smokes one pack of cigarettes daily. He denies arm or leg weakness.
Physical Examination:
- Vital signs: BP 168/92, HR 78, T 37.1C
- General: Alert, appears uncomfortable, voice is hoarse
- Neurological:
- Mental status: Alert, oriented, speech is dysarthric but content normal
- Cranial nerves:
- Left Horner syndrome (miosis, ptosis, anhidrosis)
- Horizontal nystagmus with rotatory component, worse looking left
- Decreased pinprick and temperature sensation on left face (V2, V3 distribution)
- Left palate does not elevate; uvula deviates right; absent gag on left
- Left vocal cord paralysis on laryngoscopy
- Motor: 5/5 in all extremities
- Sensory: Decreased pinprick and temperature on the right arm and leg (spared on left body; affects right side)
- Coordination: Left-sided dysmetria on finger-nose-finger; past-pointing to left
- Gait: Unable to walk without assistance; falls to left
Workup:
- Non-contrast CT head: No hemorrhage or obvious infarct
- MRI brain with DWI: Restricted diffusion in the left lateral medulla
- MR angiography: Left vertebral artery dissection with irregular narrowing
- Lipid panel: LDL 162 mg/dL
- HbA1c: 6.1%
Diagnosis: Left lateral medullary (Wallenberg) syndrome from left vertebral artery dissection
Treatment:
- Aspirin 325 mg daily
- High-intensity statin therapy
- Blood pressure management
- Speech therapy for dysphagia (NPO initially, modified diet as tolerated)
- Smoking cessation counseling
Clinical Course: Swallowing function gradually improved, and the patient was able to eat a regular diet by week 3. Vertigo and ataxia improved over 6 weeks. At 3-month follow-up, he had residual mild left-sided facial numbness and occasional vertigo with rapid head movements but was otherwise functionally independent.
Clinical Pearl: Lateral medullary syndrome produces a characteristic pattern of "crossed" sensory findings: ipsilateral face numbness (descending trigeminal tract) with contralateral body pain/temperature loss (spinothalamic tract). The ipsilateral findings (Horner syndrome, cerebellar signs, cranial nerve IX/X palsy) reflect structures damaged on the same side, while contralateral body sensory loss reflects crossing of the spinothalamic tract below the lesion. Vertebral artery pathology (dissection or atherosclerosis) is the usual cause.