Atypical Presentation of Medullary Syndrome in a Young Woman

Wallenburg syndrome occurs due to damage to lateral segment of the medulla. Medial medullarysyndrome occurs due to damage to upper portion of the medulla. I report a case of a 30 years old woman diagnosed with medullary syndrome[both medial & lateral features] in absence of CT scan findings sent to the department of Physiology for electrophysiological tests like nerve conduction studies, blink reflex, brainstem auditory evoked potential (BERA) & visual evoked potential (VEP). She had loss of sensations on the ipsilateral half of face (right), hemisensory loss on contralateral trunk & extremities, headache, contralateral hemiparesis (left), ipsilateral lingual paresis with atrophy, fibrillations with contralateral positive Babinski’s sign. The electrophysiological tests showed decrease in conduction velocity of right facial nerve, left tibial & peroneal nerves with decreased amplitude. The nerve conduction studies of median nerve (both motor & sensory) were normal. In blink reflex, latency of R2 ipsilateral & R2 contralateral of supraorbital nerves were increased on right side. There were increasedlatencies of waves II, III, IV & V of BERA & increased P100 latencies in VEP.The results of the electrophysiological tests of the patient showed that she had features of both medial & lateral medullary syndrome suggesting a lesion of both upper & middle medulla. The CT scan in this case was normal but conduction of MRI & CT guided angiography of posterior cerebral & vertebral arteries could have further localized the lesion causing this mixed symptomology

Origin of the Posterior Inferior Cerebellar Artery over the C1 Posterior Arch / Origem da artéria cerebelar inferoposterior sobre o arco posterior de C1

Resumo The posterior inferior cerebellar artery usually arises from the intracranial segment (V4) of the vertebral artery. Despite its mean diameter of 2 mm, it usually irrigates important areas of the brain. When occluded, whether due to trauma or surgery, it may cause infarction in the brain stem and cerebellum. The present report describes a case of incidental finding of a posterior inferior cerebellar artery arising from the cervical segment (V3) of the vertebral artery, demonstrated by angiography. The findings were recorded and compared to those of earlier publications. Brief explanations regarding anatomy, vascular anomalies and embryology were provided. A literature review showed that anomalous branches of the cervical segment of the vertebral artery are infrequent andmust be known. A better understanding of anatomy and its variations enables an accurate topographic diagnosis, as well as the planning of the optimal surgical approach and therapy. Knowledge of this anatomical variation is essential because, if it is mistaken for a muscle branch and coagulated, this can cause ischemia and disabling sequelae.

Resumo A artéria cerebelar inferoposterior geralmente nasce do segmento intracraniano (V4) da artéria vertebral. Apesar de ter diâmetro médio de 2 mm, usualmente irriga áreas eloquentes do encéfalo. Quando ocluída, seja por trauma ou cirurgia, pode causar infarto no tronco encefálico e no cerebelo. Apresentamos um caso de artéria cerebelar inferoposterior com origem anômala no segmento cervical (V3) da artéria vertebral, demonstrado por angiografia. Os resultados foram registrados e comparados com os de publicações anteriores. Foram fornecidas breves explicações sobre a anatomia, anomalias vasculares e embriologia. A revisão da literatura mostrou que os ramos anômalos do segmento cervical da artéria vertebral são infrequentes e devem ser conhecidos. Uma melhor compreensão da anatomia e suas variações permite fazer um diagnóstico topográfico preciso, bem como planejar a abordagem e a terapia cirúrgicas ideais. O conhecimento dessa variação anatômica é essencial, pois, se confundida com um ramo muscular e coagulada, pode causar isquemia com sequelas incapacitantes.

An outbreak of compressive myelopathy due to pyogranulomatous reaction to the oily adjuvant of the foot-and-mouth disease vaccine - case report / Surto de mielopatia compressiva associada à reação piogranulomatosa ao adjuvante oleoso da vacina contra Febre Aftosa em Minas Gerais - relato de caso

Cases of compressive myelopathy syndrome associated with post vaccinal pyogranulomas were diagnosed post mortem in three cows from a farm in Minas Gerais state, Brazil. These cows presented ataxia and bilateral paresis of the pelvic limbs, which evolved to paralysis, and sternal recumbence. On necropsy, locally extensive areas of the longissimus dorsi muscle were replaced by pyogranulomas supported by moderate amounts of fibrous connective tissue. On the cut surface, some nodules contained yellowish and viscous fluid (purulent exudate) or whitish fluid (interpreted as the oily adjuvant of a vaccine). In the spinal canal of the subjacent vertebrae, compressing the spinal cord, were pyogranulomas identical to those described in the skeletal muscle. Histologically, the pyogranulomas were composed of a central clear vacuole (consistent with the space left by the oil adjuvant droplets), surrounded by neutrophils and, more externally, by large numbers of epithelioid macrophages and fewer multinucleated giant cells. In the white matter of the spinal cord were numerous well-defined, clear vacuoles (Wallerian degeneration). The association of the clinical history and pathological findings allowed the diagnosis of compressive myelopathy associated with pyogranulomatous reaction to the oily adjuvant of the foot-and-mouth disease vaccine, in this case, due to its inadequate application.(AU)

São descritos casos de síndrome de compressão medular, associada a granulomas pós-vacinais, em bovinos Nelore, provenientes de uma propriedade em Minas Gerais. Esses bovinos apresentavam ataxia e paresia bilateral dos membros pélvicos, que evoluiu para paralisia e decúbito esternal. Na necropsia, áreas focalmente extensas da musculatura na região torácica dorsal (músculo longissimus dorsi) eram substituídas por numerosos piogranulomas, separados por tecido brancacento e firme (tecido conjuntivo fibroso). Ao corte, alguns nódulos continham material amarelado e viscoso (exsudato purulento) ou material esbranquiçado e fluido (sugestivo de adjuvante de vacina). No canal medular das vértebras subjacentes, havia granulomas idênticos aos observados no tecido muscular. Histologicamente, os piogranulomas continham, no centro, vacúolo, bem delimitado e arredondado (consistente com o espaço deixado pela gotícula de lipídio do adjuvante), circundado por variável quantidade de neutrófilos degenerados e íntegros e, mais externamente, por numerosos macrófagos epitelioides e algumas células gigantes multinucleadas. Nas áreas da medula espinhal, circundadas pelos granulomas, numerosos vacúolos, bem definidos, eram observados na substância branca (degeneração walleriana). A associação do histórico clínico e de achados patológicos permitiu o diagnóstico de mielopatia compressiva associada à reação granulomatosa ao adjuvante oleoso da vacina contra febre aftosa, no caso, induzida pela aplicação inadequada da vacina.(AU)

A case of lateral medullary syndrome with unilateral selective thermoanaesthesia

A 42-year-old female was admitted to tertiary care teaching hospital with history of headache, vertigo, difficulty in swallowing both liquids and solids, vomiting, gait ataxia, drooping of left eyelid, inability to feel hot and cold on right side of body and diplopia of forty-fivedays’ duration. Clinical examination and neuroimaging were suggestive a posterior circulation stroke, with lateral medullary syndrome.The patient had selective thermoanaesthesia on the right side, including the face, which is an atypical finding, given the clinical setting.

Opalski Syndrome Presenting as Sensorimotor Deficits Ipsilateral to Cerebral Infarction

Opalski syndrome is a rare lateral medullary infarction variant presenting with ipsilateral motor deficits known to be caused by involvement of the post-decussating pyramidal tract. Here, we report two rare cases of Opalski syndrome presenting as ipsilateral sensorimotor deficits in cerebral infarction.

A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation / 대한신경손상학회지

We describe the case of a patient who had infarction of the posterior inferior cerebellar artery (PICA) after a chiropractic cervical manipulation. A 39-year-old man visited the emergency room with signs of cerebellar dysfunction, presenting with a 6-hour history of vertigo and imbalance. Two weeks ago, he was treated by a chiropractor for intermittent neck pain. At the time of admission, brain computed tomography, magnetic resonance imaging, and angiography revealed an acute infarction in the left PICA territory and occlusion of the extracranial vertebral artery (VA; V1/2 junction) as a result of the dissection of the VA. Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. He was treated with antiplatelet therapy. Three weeks later, he was discharged without any sequelae. The possibility of VA dissection should be considered at least once in patients presenting with cerebellar dysfunctions with a recent history of chiropractic cervical manipulation.

Stellate ganglion block for the treatment of intractable hiccups: A case report

Hiccups are an involuntary contraction of the diaphragm that may repeat several times per minute. In general, hiccups are very common, transient, and self-limited. However, if the condition persists longer than days or months, it impacts a patient's quality of life. Pharmacologic and non-pharmacologic methods are used for the treatment of persistent or intractable hiccups. Nerve block and stimulation have been shown to be effective through neural pathway interruption or stimulation of the hiccup reflex arc. Stellate ganglion block (SGB) is an injection of local anesthetic adjacent to a group of nerves in the neck known as the stellate ganglion. The authors report a case of SGB as an effective treatment for a patient with intractable hiccups resulting from right lateral medullary syndrome.

Síndrome de Opalski, una variante del síndrome de Wallenberg: reporte de caso y revisión de la literatura / Opalski Syndrome, a variant of Wallenberg Syndrome: Case report and literature review

RESUMEN Se presenta un caso local de la variante de Opalski, del síndrome medular lateral (síndrome de Wallenberg) y se hace una revisión de la literatura sobre los síntomas de este cuadro clínico, así como las posibles razones que explican esta modificación en la expresión clínica. La variante de Opalski fue descrita en 1948, ochenta y nueve años después de la descripción original del síndrome por Adolf Wallenberg, su principal característica es la presencia de hemiparesia o hemiplejía del cuerpo del mismo lado de la lesión del bulbo raquídeo. La etiología es vascular en la mayoría de casos, por obstrucción de la arteria cerebelosa postero-inferior o de los ostium de vasos penetrantes que se originan en la arteria. No hay estudios que reporten la incidencia exacta de este cuadro clínico a nivel mundial, sin embargo, su presentación no es tan infrecuente. Lo más interesante al analizar cada caso, es que los hallazgos semiológicos son una muestra de la profunda organización del sistema nervioso.

SUMMARY A clinical case of the Opalski variant of the lateral medullary syndrome (Wallenberg's syndrome) is presented and a literature review about the symptoms of this clinical picture is done, as well as the possible reasons explaining this modification in the clinical expression. The Opalski variant was described in 1948, eighty-nine years after the original description of the syndrome by Adolf Wallenberg, its main feature is the presence of hemiparesis or hemiplegia of the ipsilateral side of the injury in the medulla oblongata. In most cases the etiology is vascular when the postero-inferior cerebellar artery is occluded or there is an obstruction of the ostium of penetrating vessels originating in the artery. There are no studies that accurately report the worldwide incidence of this clinical variant, however, its presentation is not uncommon. The most interesting discovery of each case is that semiological findings are a good example of the profound organization of the nervous system.

"A case of typical""Y""-shaped medullary infarction" / 天津医药

The medulla oblongata is located at the lower end of the brain stem, and it has abundant blood supply. The incidence of medial medullary infarction is low in cerebrovascular diseases. Bilateral medial medullary infarction is even rare. Bilateral medial medullary infarction is mainly characterized by paralysis. The respiratory failure can occur in severe cases. Magnetic resonance diffusion imaging can present aheartorYshaped lesion. We treated 1 patient with a typicalYshaped bilateral medial medullary infarction.

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.

A clinical study of perforating artery occlusion occurring after stent implantation of intracranial branch of vertebral artery / 天津医药

Objective To explore the methods to reduce the occlusion of perforating arteries after intracranial stenting of the vertebral artery. Methods Clinical data of 32 cases of Gateway-Wingspan stent implantation for intracranial branch of vertebral artery were retrospectively analyzed. The postoperative stricture and perfusion improvement situation were evaluated, the reason of perforating artery occlusion was analyzed. Results Thirty-two patients were implanted with 33 pieces of Wingspan stent and 1 piece of Apollo bracket. The operation success rate were 100%, and the stenosis rate reduced from (76.6±6.1)%to (27.9±5.2)%. After three months, the transcranial doppler sonography (TCD) and CT angiography were checked, showing no in-stent restenosis in all patients. Two patients occurred the perforating artery occlusion within 24 hours after operation. The possible reason was the change of stability of atherosclerotic plaque at the stenosis and the plaque displacement caused by the mechanical action of the balloon or stent, which may lead to medulla oblongata artery block. After drug and rehabilitation treatment, the symptoms in patients were improved significantly. Conclusion The perforating artery occlusion after stent implantation in intracranial branch of vertebral artery can be prevented by strict evaluation and preoperative preparation, the right selection of intraoperative balloon and stent, which still needs larger sample data to prove.

Vascular mechanisms of Wallenberg syndrome / 国际脑血管病杂志

Wallenberg syndrome is a group of clinical syndrome caused by posterior inferior cerebellar artery and vertebral artery involvement.Its most common cause is atherosclerosis,and its diversity of vascular morphology causes the variability of clinical manifestations and prognosis.This article reviews the vascular mechanisms of Wallenberg syndrome.

Unilateral Punctate Keratitis Secondary to Wallenberg Syndrome

We studied three patients who developed left unilateral punctate keratitis after suffering left-sided Wallenberg Syndrome. A complex evolution occurred in two of them. In all cases, neurophysiological studies showed damage in the trigeminal sensory component at the bulbar level. Corneal involvement secondary to Wallenberg syndrome is a rare cause of unilateral superficial punctate keratitis. The loss of corneal sensitivity caused by trigeminal neuropathy leads to epithelial erosions that are frequently unobserved by the patient, resulting in a high risk of corneal-ulcer development with the possibility of superinfection. Neurophysiological studies can help to locate the anatomical level of damage at the ophthalmic branch of the trigeminal nerve, confirming the suspected etiology of stroke, and demonstrating that prior vascular involvement coincides with the location of trigeminal nerve damage. In some of these patients, oculofacial pain is a distinctive feature.

Trigeminal Neuralgia Presenting as Transient Ischemic Attack in a Patient with Lateral Medullary Infarction

No abstract available.

A Case of Posterior Inferior Cerebellar Artery Infarction Presenting with Sudden Hearing Loss and Vertigo / 대한평형의학회지

Sudden hearing loss and vertigo are the typical presentation of anterior inferior cerebellar artery infarction, but may rarely occur in posterior inferior cerebellar artery (PICA) infarction. Here we describe a 65-year-old man who presented with sudden hearing loss in his left ear and severe vertigo. The diffusion-weighted magnetic resonance imaging revealed acute infarction in the territory of PICA and cerebral angiography showed non-visualization of left vertebral artery. Sudden hearing loss and vertigo may be a presentation of PICA infarction.

A Case of Arteriovenous Malformation Presenting as Wallenberg Syndrome / 대한이비인후과학회지

Lateral medullary syndrome, also known as Wallenberg syndrome, is characterized by sensory deficits affecting the trunk and extremities on the opposite side of the lesion, and the face and cranial nerves on the same side of the lesion. Other clinical symptoms and findings are dysphagia, slurred speech, ataxia, facial pain, vertigo with nystagmus, Horner's syndrome, diplopia, and possibly palatal myoclonus. The cause of this syndrome is usually occlusion of the posterior inferior cerebellar artery or vertebrobasillar artery. We observed a case of Wallenberg syndrome occuring secondary to the cavernous malformation and initially presenting as unilateral vocal cord palsy. The centrally-medicated vocal cord palsy is a rare cause of hoarseness, but should be considered in cases where no other local cause can be found.

A Case of Lateral Medullary Syndrome with Ipsilesional Nystagmus due to Intramedullary Hemorrhage / 대한평형의학회지

We report a rare case of primary dorsal medullary hemorrhage showing lateral medullary syndrome with ipsilesional nystagmus. A 41-year woman, presented with the first degree horizontal vestibular nystagmus and ocular tilt reaction to the left in lateral medullary hemorrhagic lesion. Primary medullary hemorrhage is rare and details of the abnormal eye movement in the lesion have never been described well. While most of the reported vestibular nystagmus in the lateral medullary infarction was contralesional., the nystagmus in this case was ipsilesional. This ipsilesional beating of the nystagmus might be explained that either destruction of the rostral part of vestibular nuclei or irritative effect of blood to vestibular nuclei is responsible. In addition, ocular tilt reaction (OTR) can be more important in deciding the side of the lesion in medullary hemorrhage

Síndrome de Wallenberg: hallazgos en resonancia magnética con correlación clínica / Wallenberg syndrome: magnetic imaging findings and clinical correlation

El síndrome de Wallenberg es una de las entidades clínicas más frecuentemente reconocidas como parte de la patología vascular del tallo cerebral. En la actualidad puede ser identificada con rapidez gracias a las modernas técnicas en neuroimagen. Presentamos un paciente con cuadro clínico de miosis, disfonía, disfagia, seguido de ataxia. Se efectuó evaluación con resonancia magnética utilizando técnicas de difusión, coeficiente aparente de difusión, FLAIR (fast fluid-attenuated inversion recovery) y perfusión. Se describe la correlación clínica de los síntomas con la localización anatómica de la lesión, y se discuten los hallazgos de imagen. La descripción de este caso enfatiza la utilidad de la resonancia magnética para una adecuada evaluación y correlación clínica de los hallazgos en imagen con la exploración neurológica.

Wallenberg's syndrome is one of the most common clinically recognized conditions due to brain stem infarct, which can nowadays be identified by modern neuro-imaging techniques. We describe a patient complaining of miosis, dysphonia, and dysphagia followed by ataxia. An MRI evaluation was performed including diffusion-weighted imaging, apparent diffusion coefficient, T2-weighted images, fluid attenuated inversion recovery (FLAIR) and perfusion. A brief discussion of imaging findings is presented as well as a clinical correlation of the symptoms with the anatomic location of the lesion. This case report emphasizes the importance of imaging findings and their clinical correlation with neurological examination.

Ipsilateral Axial Lateropulsion as an Initial Symptom of Lateral Medullary Infarction: a Case Report

The dorsolateral medullary syndrome (Wallenberg's syndrome) is produced by infarction of a wedge of lateral medulla posterior to the inferior olivary nucleus, and is usually caused by vertebral artery occlusion. Ipsilateral axial lateropulsion as an initial symptom of vertebral artery occlusion is rare, and the responsible anatomical structure is still uncertain. Here we describe a patient presenting with ipsilateral axial lateropulsion as an initial symptom of vertebral artery occlusion.

Lateral Medullary Syndrome Caused by Prone Position for Spine Surgery

We report a rare case of Wallenberg's lateral medullary syndrome caused by prone position for spine surgery. A 48-yearold man developed Wallenberg's syndrome characterized by involuntary myoclonic movements, ataxia on his left side, hyperalgia and cold sensation on his right side after prone position for general anesthesia for the spinal stenosis L3-L4, L4-L5. Brain computed tomography scan was immediately performed and showed negative findings, but magnetic resonance image (MRI) demonstrated brain infarction on the left medulla. Emergent heparinization was performed and his motor power and sensation returned to normal and discharged with stable and satisfactory recovery after 16 days.