Abstract
Wallenberg syndrome is the most common stroke of the posterior circulation. Diagnosis of Wallenberg syndrome is often overlooked as initial MRI may show no visible lesion. We present an atypical case of Wallenberg syndrome in which the initial MRI of the brain was normal.Our patient is a 65-year-old male who was brought in by emergency medical services complaining of right-sided facial droop, slurred speech, and left-sided weakness for one day. Physical examination showed decreased left arm and leg strength compared to the right side, decreased left facial temperature sensations, decreased left arm and leg temperature sensations, and difficulty sitting upright with an associated leaning towards the left side. An initial magnetic resonance imaging (MRI) of the brain with and without contrast revealed no abnormality. In light of such a high suspicion for stroke based on the patient’s neurologic deficits, a repeat MRI of the brain was performed three days later and exposed a small focus of bright signal (hyperintensity) on T2-weighted fluid-attenuated inversion recovery and diffusion-weighted imaging (DWI) in the left posterior medulla.Wallenberg syndrome, also known as lateral medullary syndrome or posterior inferior cerebellar artery syndrome, is a constellation of symptoms caused by posterior vascular accidents. The neurological deficits associated with this disease are due to damage of the lateral medulla, inferior cerebellar peduncle, nucleus of trigeminal nerve, nucleus and fibers of vagus and glossopharyngeal nerves, descending sympathetic tract, spinothalamic tract, and/or vestibular nuclei. MRI with DWI is the gold standard to confirm the diagnosis.Wallenberg syndrome has the potential to leave patients extremely debilitated. Early detection, management, and rehabilitation are critical for improving post-stroke recovery.
Highlights
20% of all strokes that occur annually in the United States are located in the posterior circulation [1]
Wallenberg syndrome, known as lateral medullary syndrome or posterior inferior cerebellar artery syndrome, is a constellation of symptoms caused by posterior vascular accidents
Categories: Internal Medicine, Neurology, Anatomy Keywords: wallenberg syndrome, neurology, ambiguous, internal medicine, mri Approximately 20% of all strokes that occur annually in the United States are located in the posterior circulation [1]
Summary
20% of all strokes that occur annually in the United States are located in the posterior circulation [1]. The patient reported that he returned home from breakfast one day ago, sat on the front steps of his home, and suddenly felt dizzy and "passed out." It was unknown how long he lost consciousness as it was unwitnessed He denied a prior history of stroke or myocardial infarction. An initial magnetic resonance imaging (MRI) of the brain with and without contrast revealed no abnormality (Figures 1, 2) In light of such a high suspicion for stroke based on the patient’s neurologic deficits, a repeat MRI of the brain was performed three days later and exposed a small focus of bright signal (hyperintensity) on T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) (Figure 3) and diffusion-weighted imaging (DWI) in the left posterior medulla (Figure 4). The patient was started on antibiotics for his urinary tract infection, highintensity statin therapy, low-dose aspirin therapy, and eventually discharged to subacute rehabilitation for further management once medically stabilized
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