Case series and literature review of Opalski syndrome: A rare brainstem stroke

@#A rare type of lateral medullary infarction, the Opalski Syndrome is weakness ipsilateral to the lesion of the infarct. The lesion involves the ipsilateral corticospinal tract below the pyramidal decussation. We report the first two known documented case in the Philippines, admitted on the same tertiary hospital almost one year apart.

Síndrome de Wallenberg asociado a una arteria vertebral derecha hipoplásica bifurcada: Primer reporte de un caso en el Perú / Wallenberg syndrome associated with a bifurcated hypoplastic right vertebral artery: First case report in Peru

Resumen El síndrome de Wallenberg es el accidente cerebrovascular isquémico más común de la circulación posterior, causado por una obstrucción aterotrombótica en la arteria vertebral o la arteria cerebelosa posteroinferior. Esta oclusión origina una isquemia en la porción lateral del bulbo que resulta en la triada representativa del síndrome de Horner, ataxia ipsilateral a la lesión y alteraciones sensitivas. El riesgo de padecer este cuadro es mayor si se tiene variaciones anatómicas tales como una arteria vertebral hipoplásica y/o duplicada. Se presenta el caso de una mujer de 45 años admitida por hipoestesia en el lado derecho del rostro y en el hemicuerpo izquierdo, así como disfagia y vómitos. La resonancia magnética reveló una lesión isquémica en la zona bulbar lateral derecha; en la angiorresonancia se evidenció una arteria vertebral derecha hipoplásica, en tanto que la angio-TEM del cuello mostró una arteria vertebral derecha hipoplásica y bifurcada. En base a la clínica y exámenes radiológicos se confirmó el diagnóstico de Síndrome de Wallenberg, causado por isquemia en el territorio de la arteria vertebral derecha hipoplásica bifurcada.

Summary Wallenberg syndrome is the most common ischemic stroke of the posterior circulation, caused by an atherothrombotic obstruction of the vertebral or the postero-inferior cerebellar artery. This occlusion leads to ischemia in the lateral portion of the bulb, which results in the representative triad of Horner's syndrome, ataxia on the ipsilateral side of the lesion and sensory alterations. There is a greater risk of suffering from this condition with anatomical variations such as a hypoplastic and/or duplicated vertebral artery. The case of a 45-year-old woman admitted as an emergency due to hypoesthesia on the right side of the face and on the left side of the body, as well as dysphagia and vomiting is reported. MRI studies revealed an ischemic lesion in the right-side of the bulbar area; in the angio-MRI a hypoplastic right vertebral artery was evidenced whereas the angio-TC showed a hypoplastic and duplicated right vertebral artery. On the basis of the clinical and radiological examinations, the diagnosis of Wallenberg syndrome caused by bifurcated hypoplastic right vertebral artery ischemia, was confirmed.

Cricopharyngeal Botulinum Toxin Injection under Ultrasonic Guidance for Dysphagia from Wallenberg's Syndrome: A Case Report / 中国康复理论与实践

Objective:To investigate the effect of cricopharyngeal injection of Botulinum toxin under ultrasonic guidance for treatment of dysphagia caused by Wallenberg's syndrome. Methods:A case was reviewed. Results:This patient was diagnosed as cricopharyngeal achalasia after dorsal lateral rostral infarction, and responded poor to routine treatment for swallowing disorders, including balloon dilatation. He accepted cricopharyngeal Botulinum toxin injection under ultrasonic guidance. As evaluated with Toshima Ichiro Ingestion-Swallowing Function Rating Scale, Rosenbek Penetration-Aspiration Scale and videofluoroscopic swallowing study (VFSS), his swallowing improved after treatment, and became normal as follow-up one and three months after treatment. Conclusion:Cricopharyngeal Botulinum toxin injection under ultrasonic guidance is feasible for cricopharyngeal achalasia of Wallenberg's syndrome with immediate and long-term effect.

Síndrome de Wallenberg: reporte de caso / Wallenberg Sindrome: a case report

El Síndrome de Wallenberg representa el 36% de los infartos del tronco cerebral. Se debe a la oclusión de la Arteria cerebelosa posterior inferior, afectando estructuras encontradas en el cerebelo y la parte lateral del bulbo raquídeo. El principal factor de riesgo es la aterosclerosis. El caso se trata de paciente masculino de 57 años de edad con antecedente de Infartos lacunares en cerebelo, Diabetes mellitus tipo 2No controlada, tabaquismo y dislipidemia. Inicia con cuadro clínico de cefalea occipital, intensa, súbita, sin atenuantes concomitantemente vértigo, hipo, nauseas, vómitos y parestesia de miembros inferiores. Al examen físico pulsos periféricos disminuidos, presenta Síndrome de Horner, hipo, hipoestesia en hemicara izquierda y hemicuerpo contralateral, con ataxia, dismetría y disdiadococinesia. Se realiza IRM con difusión con conclusión diagnostica: Imagen hiperintensa de morfología irregular en el contorno lateral izquierdo del bulbo raquídeo por restricción molecular, compatible con evento isquémico (Síndrome Wallenberg). Se indica tratamiento antitrombótico y terapia física. Paciente es evaluado 2 meses después mostrando amplia mejoría de su cuadro. Es un síndrome muy específico, cuya manifestación clínica depende de la región anatómica afectada y abstrae al clínico de otros diagnósticos.

Wallenberg's Syndrome represents 36 % of strokes in the brainstem. It is due to occlusionof the inferior cerebellar artery, affecting structures found in the cerebellum and the lateral part of themedulla oblongata. The main risk factor is atherosclerosis. The case is about a 57-year-old male patient witha history of lacunar infarcts in the cerebellum, type 2 diabetes mellitus, smoking and dyslipidemia. It beginswith an intense and sudden occipital headache, without attenuating, concomitantly vertigo, hiccups, nausea,vomiting and paresthesia of lower limbs. At the physical examination, decreased peripheral pulses presentHorner's syndrome, hypoesthesia, hypoesthesia in left hemiface, and contralateral hemibody, with ataxia,dysmetria and dysdiadochokinesia. MRI was performed with diffusion with diagnostic Hyperintense image ofirregular morphology in the left lateral contour of the medulla oblongata, compatible with ischemic event(Wallenberg syndrome). Antithrombotic treatment and physical therapy was indicated. Patient was evaluated2 months later showing ample improvement. It is a very specific syndrome, whose clinical manifestationdepends on the anatomical region affected and abstracts the clinician from other diagnoses.

Clinical observation on the treatment of dysphagia in the patients with Wallenberg syndrome by intermittent oro-esophageal tube feeding / 肠外与肠内营养

Objective:To observe the clinical effect of intermittent oro-esophageal tube feeding (IOE) in the treatment of swallowing disorder caused by Wallenberg syndrome dorsal lateral syndrome,and to find new treatment for this kind of patients.Methods:60 cases of Wallenberg syndrome dorsal lateral syndrome were selected and randomly divided into the IOE group and the NGT group.All the patients were given swallowing function training based on controlling of the primary diseases,intervene modifiable risk factors and stroke prevention.The nutrition index and swallowing function were evaluated and compared in 24h after admission and 6 weeks after treatment.Results:Compared with the NGT group,the nutrition and swallowing function in IOE group were better.The differences were statistically significant (P ＜ 0.05).Conclusion:Intermittent oro-esophageal tube feeding is more conducive to the improvement of nutrition and swallowing function in patients with Wallenberg syndrome than NGT.

Disfagia orofaríngea na Síndrome de Wallenberg - série de casos / Oropharyngeal dysphagia in Wallenberg's syndrome - case series

RESUMO: Objetivo: caracterizar o quadro de comprometimento da função da deglutição em pacientes com Síndrome de Wallenberg. Métodos: série de casos de sete pacientes, com diagnóstico dessa síndrome, encaminhados para avaliação fonoaudiológica. Para avaliação do grau de disfagia utilizou-se a escala Gugging Swallowing Screen e para avaliar o nível de ingestão oral utilizou-se a Functional Oral Intake Scale. Resultados: a média de idade foi de 60,57 anos; todos os sujeitos apresentaram alteração na função da deglutição de grau grave (71,42%) a moderado (28,58%); 85,71% necessitaram de Via Alternativa de Alimentação, sendo que, 71,43% eram alimentados exclusivamente por sonda nasoentérica; todos necessitaram de acompanhamento fonoaudiológico. Conclusão: este estudo concluiu que a disfagia orofaríngea na Síndrome de Wallenberg apresenta-se como um distúrbio de grau grave a moderado, sendo necessária a utilização de Via Alternativa de Alimentação na maioria dos casos.

ABSTRACT: Purpose: characterizing the impairment condition of the swallowing function in patients with Wallenberg Syndrome. Methods: case series of seven patients, with diagnosis of this syndrome, referred for phonological assessment. The Gugging Swallowing Screen scale was used to evaluate the level of dysphagia and the Functional Oral Intake Scale was used to evaluate the level of oral ingestion. Results: the mean age was 60.57 years; all subjects presented changes in the function of swallowing of severe degree (71.42%) to moderate degree (28.58%); 85.71% required Alternative Feeding Route, wherein, 71.43% were fed exclusively by nasoenteric tube; all subjects required speech therapy. Conclusion: this study concluded that oropharyngeal dysphagia in Wallenberg Syndrome presents itself as a disorder of serious to moderate degree, being the use of Alternative Feeding Route required in most cases.

Lateral medullary infarct/Wallenberg Syndrome: Jamaica / Síndrome de Wallenberg/Infarto medular lateral: Jamaica

We describe two cases of lateral medullary syndrome at the University Hospital of the West Indies, Mona, Jamaica. This diagnosis is often missed and not well understood, so we will discuss the underlying pathophysiology.

Se describen dos casos de síndrome medular lateral en el Hospital Universitario de West Indies, Mona, Jamaica. Este diagnóstico pasa a menudo inadvertido y no es bien entendido. Por esa razón se discute aquí la patofisiología subyacente.

A Case of Delayed-onset Wallenberg's Syndrome following Cervical Spine Fracture coexisting with suspected Conversion Disorder / The Japanese Journal of Rehabilitation Medicine

We experienced a case of delayed-onset Wallenberg's syndrome following cervical spine fracture coexisting with suspected conversion disorder. A 69-year-old man was involved in a traffic accident, and was admitted to our rehabilitation unit for the purpose of posttraumatic rehabilitation. At first, he complained of right occipital and nuchal pain. But his complaints changed to ataxia, dysphagia and a suspected brainstem lesion four months after the accident. His brainstem MRI showed a small ischemic lesion in the right dorsolateral area of the medulla oblongata. The long time lag between the original traumatic event and his changing complaints made the diagnosis difficult. Accordingly, rehabilitation assessment and conventional rehabilitation approaches were prepared for all of his symptoms. The dysphagia and ataxia were gradually reduced and the hemiparesis lessened and disappeared. A couple of points were suggested by this case. The first is “We must never overlook a change of neurological symptom masked as conversion disorder, and never deny what the patient says without careful listening.” The second is “We should offer the patient a conventional rehabilitation program without the option for malingering and falsification. This case might suggest that our attitude toward so-called gray-zone cases has an influence on the functional/social prognosis.

Improvement of Quiet Standing Balance in Patients with Wallenberg Syndrome after Rehabilitation

OBJECTIVE: To evaluate quiet standing balance of patients with Wallenberg syndrome before and after rehabilitation. METHOD: Six patients with Wallenberg syndrome were enrolled within one month after being affected by an infarct of the lateral medulla. Quiet standing balance was assessed using posturography with eyes open and closed. The assessment was repeated after the patients had undergone rehabilitation treatment for three to nine months, and the results of the two assessments were compared. RESULTS: The quiet standing balance evaluation was performed by measurement of center of pressure (CoP) movement. In the initial test, the mean scores of mediolateral and anteroposterior speed, velocity movement, mediolateral and anteroposterior extent of CoP were all high, indicating impairments of quiet standing balance in the patients. After rehabilitation treatment, the anteroposterior speed and extent, the mediolateral speed and extent, and velocity moment of CoP showed statistically significant reductions in the eyes open condition (p<0.05), and the anteroposterior speed and extent and velocity moment of CoP had decreased in the eyes closed condition (p<0.05). Mediolateral speed and extent of CoP in the eyes closed condition had also decreased, but the reduction was not statistically significant. CONCLUSION: This study demonstrated improvements of quiet standing balance, especially anteroposterior balance, in patients with Wallenberg syndrome following rehabilitation. We suggest that balance training is important in the rehabilitation of Wallenberg syndrome and that, as an objective measure of balance status, posturography is useful in the assessment of quiet standing balance.

Síndrome de Wallenberg secundária a aneurisma gigante de artéria vertebral / Wallenbergïs syndrome due to giant aneurysm of the vertebral artery

Descrevemos um caso de síndrome bulbar lateral, também conhecida pelo epônimo síndrome de Wallenberg, em uma paciente do sexo feminino de 46 anos, com todos os sinais e sintomas clássicos, determinada por aneurisma gigante do segmento intracraniano da artéria vertebral. A síndrome de Wallenberg, apesar de comum a sua apresentação como consequência de aneurisma gigante de artéria vertebral, não é frequente, e na patogênese da sintomatologia o efeito de massa dessas lesões deve ser considerado.

We present a case of lateral bulbar syndrome, or Wallenbergïs syndrome, in a 46 year-old woman with all classic signs and symptoms, due to giant aneurysm of the vertebral artery at its intracranial segment. Even though common, Wallenberg syndrome due to giant aneurysm is not frequent, and in its pathogenesis the mass effect of this lesions may have a significant role.

Síndrome de Wallenberg: a propósito de un caso / Wallenberg syndrome: report of a case

Se trata de paciente de sexo masculino, de 47 años de edad, quien ingresa a la emergencia del Hospital “Dr Héctor Nouel Joubert” del IVSS de Ciudad Bolívar por presentar disartria de aparición brusca, disfagia, hemiparesia derecha e hipo intermitente. Al examen físico se encontraron cifras tensionales elevadas (160/80mmHg), voz ronca, lengua lateralizada a la derecha, ptosis velopalatina derecha discreta, hemihipoestesia facial derecha con hemihipoestesia térmica izquierda, hemiparesia derecha, reflejo nauseoso ausente en el lado derecho, todo por afectación de los pares craneales: V, VII, IX, X y XII. Se realizó resonancia magnética contrastada con énfasis en fosa posterior, revelando imagen de 6 mm en bulbo raquídeo, correspondiente a oclusión aterotrombótica de la arteria cerebelosa posterior izquierda, lo cual explica la clínica del paciente. Debe resaltarse el inicio brusco de la sintomatología del paciente y que, a diferencia de otros casos presentados, éste no comenzó con vértigo, náuseas y vómitos, así como tampoco la presencia del Síndrome de Horner ipsilateral, descrito en algunos casos de Síndrome de Wallenberg

A 47-years old male patient admitted to the emergency service of the Dr. Héctor Nouel Joubert Venezuelan Institute of Social Security Hospital of Ciudad Bolivar presented with sudden-onset dysarthria, dysphagia, right-sided hemiparesis, and intermittent hiccups. A physical evaluation revealed high blood pressure (160/80mmHg), hoarseness, tongue deviation to the right, discrete ptosis of the soft palate, right facial hemihypoesthesia with left thermal hemihypoesthesia, right-sided hemiparesis and absent gag reflex on the right side all due to impairment of cranial nerves V, VII, IX, X, and XII. A contrast-enhanced MRI with focus on the posterior fossa revealed a 6mm image in the medulla oblongata, corresponding to an atheroembolic occlusion of the left posterior cerebellar artery, which explains the patient’s bodily disorder. It is worth noting that the symptoms appeared suddenly and, unlike in other cases, they did not include vertigo, nausea, pr vomits, nor the ipsilateral Horner’s Syndrome described in some cases of Wallenberg’s Syndrome

A Case of Acupuncture Treatment for Indefinite Complaints Accompanying Wallenberg Syndrome / 全日本鍼灸学会雑誌

[Objective] For objective investigation of symptomatic changes in indefinite complaints accompanying Wallenberg syndrome, efficacy of acupuncture treatment was investigated following seven acupuncture treatments using charts on indefinite complaints developed by Yasuzo Kurono, the chief of the Indefinite Complaint Section in the Japan Society of Acupuncture and Moxibustion, Research Committee.<BR>[Design] A case report providing descriptive research<BR>[Methods] Single acupuncture was administered by zuishou therapy (therapy based on the symptoms), taikyoku therapy (basic meridian points for total body adjustment according to the Kurono style) and topical therapy, using 30-mm 16-guage needles. The charts on indefinite complaints were used for assessment, and the treatment period was 52-days, from May 20 to July 10, 2003 (seven times).<BR>[Results] Improvement of the indefinite complaints was observed, and effect assessment using the charts on indefinite complaints showed marked improvement. Improvement of symptoms associating Wallenberg syndrome was also observed.<BR>[Conclusions] Efficacy of acupuncture treatment for the indefinite complaints accompanying Wallenberg syndrome was suggested by the improvement of symptoms associated with Wallenberg syndrome. The patient subsequently returned to work, indicated the potential of acupuncture treatment as QOL.

Diagnosis and Management of the Spontaneous Intracranial Vertebral Artery Dissection

The authors have dealt with six cases of spontaneous intracranial vertebral artery dissection during the past 3 years. Most of the patients were in their fourth or fifth decade of life, and men predominated. All except one patient had severe antecedent headache and half of the 6 cases were hypertensive. The presenting clinical features were subarachnoid hemorrhage, Wallenberg's syndrome, brain stem RIND(reversible ischemic neurologic deficit) and cerebellar infarct. The locations of the dissection were right vertebral artery in four patients, right vertebral and basilar artery in one and left vertebral artery in another one. Most of the patients showed typical intramural hematoma or double lumen on the MRI. In the MR angiography, irregular segmental narrowing of vertebral artery or invisible pathologic vertebral artery were demonstrated. The angiographic findings included alternating irregular stenotic and dilated segment(pearl and string sign), aneurysmal dilatation, occlusion etc. four patients were treated medically while the other two were treated surgically by proximal vertebral artery clipping of the affected artery. Upon follow-up, the outcome were excellent in two, good in two and fair in two.

The Effect of Acupuncture Therapy on Abnormal Eye Movement in Wallenberg's Syndrome / 全日本鍼灸学会雑誌

INTRODUCTION<br>There have been very few reports on the effects of acupuncture on abnormal eye movements often seen in patients with central vertigo. Recently we had the opportunity to apply acupuncture to a case of Wallenberg's syndrome, which displays a peculiar nystagmus and vertigo. This case is reported because the effectiveness of acupuncture in improving the eye movement was proved by the electronystagmography (ENG) in collaboration with the Nihon University School of Medicine.<br>CASE REPORT<br>Patient: A 47 year old man. Diagnosis: Wallenberg's syndrome. Chief Complaint: Vertigo. Present Illness: In Nov. 1980, the patient noticed a loss of pain and temperature sense in his right limb, followed by vertigo. He was admitted to the Nihon Univ. Hospital in Dec. 1980. CT-examination of the whole body, a vertebral arteriogram, etc. indicated a circulatory failure in the left lateral area of the medulla oblongata.<br>In Mar. 1981, the patient visited our clinic with the chief complaint of vertigo. Present Condition: He complained of rotary vertigo. The orthostatic test was positive with both opened and closed eyes. A decrease in the pain and temperature sense on the right side of the body, except for the head, was observed.<br>COURSE<br>Acupuncture was applied to the posterior region of the neck, the back, and the lateral of the lower extremity in order to relax the muscles of these parts. After acupuncture the patient reported a decrease in his vertigo. After the twentieth session of acupuncture the symptoms improved to the extent that he could go out alone. After the twenty-second session, he returned to work. Although his vertigo and nystagmus did not completely disappear, an obvious improvement in these symptoms was seen after each session, and this improved condition remained for two or three days. With the ENG recorded before, shortly after, and 30min. after a session of acupuncture therapy, a decrease in abnormal eye movement after the session was confirmed.<br>CONCLUSION<br>Acupuncture therapy was applied to a case of Wallenberg's syndrome.<br>Result:<br>1. A short-term decrease in vertigo was observed.<br>2. A decrease in abnormal eye movement after acupuncture therapy was confirmed by electronystagmography.