Neurology · Year 3 · from Neurology

Case 2: Wallenberg Syndrome (Lateral Medullary Stroke)

Patient Demographics

  • Age: 58 years
  • Sex: Male
  • Occupation: Truck driver

Chief Complaint

"I feel like I'm spinning, and I can't swallow properly."

History of Present Illness

Sudden onset of severe vertigo, nausea, and vomiting while driving. He pulled over and noticed difficulty swallowing his saliva. His voice became hoarse. He also felt numbness on the left side of his face and the right side of his body. He has a 40-pack-year smoking history and untreated hypertension.

Neurological Examination Findings

Mental Status:

  • Alert and oriented x3
  • Speech: Hoarse, dysarthric

Cranial Nerves:

  • CN V: Decreased sensation left face (all divisions)
  • CN VIII: Horizontal nystagmus, fast phase to right; no hearing loss
  • CN IX/X: Absent left gag reflex, uvula deviates to right, hoarse voice
  • CN XI: Left shoulder shrug weakness
  • CN XII: Tongue midline

Motor Examination:

  • 5/5 strength throughout all extremities

Sensory Examination:

  • Decreased pain/temperature: Left face, right arm, right trunk, right leg
  • Vibration and proprioception intact throughout

Reflexes:

  • 2+ symmetric throughout
  • Plantar responses flexor bilaterally

Coordination:

  • Left finger-to-nose: Mild dysmetria (ipsilateral cerebellar signs)
  • Left heel-to-shin: Mild ataxia
  • Right side: Normal

Gait:

  • Ataxic, tends to fall to the left
  • Romberg positive

Other:

  • Left Horner syndrome: Ptosis, miosis, anhidrosis

Localization

Lesion Location: Left lateral medulla (Wallenberg Syndrome)

  • Ipsilateral facial sensory loss (descending trigeminal tract)
  • Contralateral body pain/temperature loss (spinothalamic tract)
  • Ipsilateral Horner syndrome (descending sympathetics)
  • Dysphagia/hoarseness (nucleus ambiguus - CN IX, X)
  • Ipsilateral cerebellar signs (inferior cerebellar peduncle)
  • Vertigo/nystagmus (vestibular nuclei)

Vascular territory: Posterior inferior cerebellar artery (PICA) or vertebral artery

Neuro Workup

  • CT Head: No hemorrhage, no acute changes
  • MRI Brain (DWI): Restricted diffusion in left lateral medulla
  • MRA Head/Neck: Left vertebral artery dissection with high-grade stenosis
  • CT Angiography: Confirms left vertebral dissection
  • Echocardiogram: Normal, no PFO

Diagnosis

Left lateral medullary infarction (Wallenberg Syndrome) secondary to left vertebral artery dissection

Management

Acute:

  1. Aspirin 325 mg initially, then anticoagulation given dissection
  2. NPO - failed bedside swallow evaluation
  3. Speech therapy for swallowing rehabilitation
  4. IV fluids and NGT for nutrition

Secondary Prevention:

  1. Anticoagulation with heparin bridge to warfarin (INR goal 2-3) for 3-6 months
  2. Repeat imaging at 3 months to assess dissection healing
  3. Smoking cessation counseling
  4. Blood pressure control
  5. Statin therapy

Prognosis: Generally good; dysphagia may persist for weeks to months

Clinical Image

Image Description: MRI DWI sequence showing restricted diffusion in the left lateral medulla, consistent with acute infarction (Wallenberg syndrome).

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/wallenberg-syndrome-2

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