History –
55 year old male with no prior medical history (he hasn’t seen a doctor or taken any medication during his entire adult life due to religious preferences). He presents with 1-2 months of increasing fatigue, lower extremity edema, dyspnea and 1 day of neuro changes. Neuro changes include very slight confusion, mildly slurred speech, swallowing difficulties and coordination problems of right arm.
PMhx – none
Meds – none
Allergies – none
SHx – Christian Scientist, no drugs or alcohol
Exam:
VS Pulse 155, BP 180/110, RR 14, O2 92% on RA, Temp 98.8 F
Gen: Obese male, slightly odd affect and slow speech, but no acute distress
HEENT: Unremarkable
Cardiovascular: Tachy and irregularly irregular
Respiratory: no distress, mild crackles at bases
Abdomen: Obese, Non-Tender
Lower Extremities: 3+ edema with some weeping of clear fluid, no open wounds
Neurologic: A&O x 3 but somewhat slow to respond, affect a bid odd
CN – No facial droop. There is decreased sensation to light touch over right face.
Strength – 5/5 b/l UE and LE
Sensation – decreased sensation to pain in Left arm
Coordination – Mild pronator drift and dysmetria with FNF in RUE.
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What’s next?
1) Workup and treat the Atrial Fibrillation with RVR (Easy).
2) What’s with the crossed deficits on neuro exam? Of course you are going to speak with neuro and get an MRI/MRA on this guy but is this diagnostic for any particular stroke syndrome (yes, it is).
DDx: CVA (ischemic, hemorrhagic), encephalitis, brain mass, Multiple Sclerosis, Toxic, metabolic
You desperately try to remember all of those complicated neuro pathways?
MRI Results: Acute infarct within the right inferior cerebellum and dorsal medulla predominantly in the right PICA distribution. Mass-effect upon the 4th ventricle with near-complete effacement. No hydrocephalus.
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Wallenberg Syndrome aka Lateral Medullary Syndrome aka PICA syndrome
Lateral Medullary Infarction caused by occlusion of the PICA or the vertebral artery. Most common causes: embolic, atherosclerotic, vertebral artery dissection. Long-term prognosis depends on degree of deficits and size of infarct but usually is quite good. TPA can be considered as a treatment if no exclusionary criteria. Death in acute phase can be caused by aspiration and apnea spells during sleep.
Now I remember...
Typical Signs and Symptoms:
- vestibulocerebellar
- Sensory
- Bulbar Muscle Weakness
- Respiratory Dysfunction
- Autonomic Dysfunction
o Vertigo/disequilibrium, difficulty sitting upright (lean towards lesion)
o hypotonia of ipsilateral arm
o blurred vision
o Nystagmus (horizontal and rotational)
o Ipsilateral limb ataxia (finger-nose-finger)
o Paresthesia/pain in ipsilateral face (CN V)
o Loss of pain/temp on contralateral trunk/limbs (spinothalamic tract)
o Combo of sensory changes on ipsilateral face and contralateral trunk/limbs is diagnostic of Wallenberg Syndrome
o Hoarsenss, dysphagia, aspiration problems, uvula may deviate away from lesion, dysarthria
o Can have failure of automatic respirations during sleep
o Ipsilateral horner’s syndrome
o CV problems – tachycardia, orthostatic hypotension, labile BP
Questions:
1) Wallenberg Syndrome or Lateral Medullary Infarction is typically caused by lesions in what artery distribution?
a. MCA
b. PICA
c. AICA
d. Internal Carotid
2) True or False: The combination of contralateral face sensory changes and ipsilateral trunk/limb loss of pain/temp is diagnostic for Wallenberg Syndrome.
3) Which of the following is not a common sign or symptom seen in Wallenberg Syndrome?
a. Dysphagia
b. Vertigo
c. Ipsilateral limb ataxia
d. Rotational nystagmus
e. Hemiplegia
4) What is one of the most common causes of death in the acute phase of Wallenberg Syndrome?
a. Herniation
b. Severe hyponatremia
c. Aspiration
d. Inappropriate tpa administration
5) True or False: Intractable hiccups are an infrequent but specific symptom sometimes associated with Wallenberg Syndrome.
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Answers:
1. b
2. True
3. e
4. c
5. False
Bonus Question: Can you name the city in which the following building is located? (Hint, Mark Wallberg would get this...no prAHblem.)
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