Simultaneous Occurrence of Transient Complete Heart Block With Acute Lateral Medullary Infarct.

Lateral Medullary Syndrome (LMS) poses clinical challenges, often resulting from ischemic events in the medulla oblongata. We present a unique case of LMS in a woman in her 60s with a complex medical history. Alongside neurological deficits, she experienced a transient high-grade atrioventricular block (HgAVB), a rare cardiac manifestation linked to LMS. Given the rarity of simultaneous transient HgAVB with acute lateral medullary infarct, only a handful of case reports documenting similar findings are available in the existing literature. More research and case reporting are needed to better our understanding of this area. The patient's condition, marked by a sudden onset of severe headache and left-sided weakness, revealed an acute infarct in the medulla territory. Notably, her HgAVB spontaneously resolved after 72 hours. This case emphasises the crucial need for extended cardiac surveillance in LMS patients due to their susceptibility to life-threatening arrhythmias. The intricate interplay between the brainstem and cardiovascular system highlights autonomic dysregulation as a potential mechanism for cardiac abnormalities. The report advocates for a holistic approach to managing LMS cases, stressing interdisciplinary collaboration for timely diagnosis and intervention, ultimately improving patient outcomes and reducing the risk of fatal arrhythmias.

Lateral medullary syndrome in a resources limited hospital: A rare clinical anatomical variation of ischemic stroke.

Key Clinical Message: Although it is rare, physicians should be familiar with the presentation of lateral medullary syndrome (LMS). Urgent neuroimaging is crucial to distinguish LMS from other causes of stroke. The majority experience significant improvement within months. Abstract: Lateral medullary syndrome is a rare type of stroke resulting from a vascular event in the lateral part of the medulla oblongata. Loss of pain and temperature in the ipsilateral side of the face, and contralateral side of the body along with ipsilateral ataxia, vertigo, nystagmus, dysphagia, and hiccups are the hallmark clinical presentation. We reported a case of a 51-year-old male with a long history of smoking and newly discovered hypertension who presented complaining of vomiting, regurgitation, and hiccups for 1 month; tingling and numbness sensation in the left side of the face and the right side of the body, and unsteady gait for 2 weeks. Neurological examinations revealed left-sided ptosis and miosis, diminished sensation of the three divisions of the trigeminal nerve, deviated uvula to the right side, absent gag reflex, and intention tremors. The patient received the appropriate treatment; showed a good recovery with his symptoms, was able to walk unsteady, and was discharged after 10 days in a good condition.

Opalski Syndrome and Elucidation of Lateral Medullary Syndrome.

In this case, a 61-year-old patient presented with Horner's syndrome of the left eye, left-sided truncal ataxia, left-sided pain/paresthesia of the face as well as right-sided loss of pain and temperature of the arms and legs. MRI findings displayed a clear 4 mm acute left lateral medullary infarct of the left posterior inferior cerebellar artery (PICA) vascular territory, indicative of lateral medullary syndrome (LMS). The presence of pre-existing medical conditions such as uncontrolled diabetes, late-stage syphilis, and a mechanical aortic valve complicated this clinical picture. The presence of ipsilateral corticospinal deficits in this patient revealed Opalski syndrome, a rare variant of LMS. This case report highlighted the importance of correlating imaging and physical examination of stroke findings.

Lateral Medullary Infarction With Atonic Bladder and Lateropulsion.

Lateral medullary infarction (LMI), or Wallenberg syndrome, can develop various symptoms, but it is rare that ipsilateral axial lateropulsion (or body lateropulsion, BL) or atonic bladder (AB) are caused by LMI. This report describes a case of LMI with both BL and AB. A 77-year-old man, with a history of hypertension and diabetes, developed acute left BL and anuresis. A neurological exam showed right gaze nystagmus, slight dysarthria and dysphagia, right dysesthesia in the trunk, and ataxia in the left limbs and trunk. Horner's syndrome and paralysis were unremarkable. Brain magnetic resonance imaging revealed hyperintensity in the lateral medulla oblongata. Cystometry revealed AB, although the patient had the urge to urinate. Owing to acute therapy, although trunk ataxia was presented for several months, BL and anuresis were recovered on day 15 and day 35, respectively. Here, we describe the potential mechanisms of BL and AB caused by LMI.

Usefulness of thermography for differentiating Wallenberg's syndrome from noncentral vertigo in the acute phase.

OBJECTIVES: Wallenberg's syndrome (WS) is caused by a stroke in the lateral medulla and can present with various symptoms. One of the main symptoms is vertigo, which can be misdiagnosed as noncentral vertigo (NCV). Approximately 90% of the patients with acute WS have a lateral difference in body surface temperature (BST) due to autonomic pathway disturbances from infarction. Additionally, thermography can aid in WS diagnosis; however, whether BST differences occur in patients with acute NCV is unclear. METHODS: This study used thermography to measure the BST of patients with NCV and acute WS to determine the effectiveness of BST to differentiate between the conditions. Forty-eight consecutive patients diagnosed with NCV whose BST was measured using thermography during a hospital visit or admission were enrolled. The left and right BST of four sites (face, trunk, and upper and lower limbs) were measured and compared with obtained BST of nine patients with WS. RESULTS: Twenty-two patients had lateral differences in BST ≥ 0.5°C, three with ≥1.5°C, and none with ≥2.5°C. Only one patient with NCV had lateral differences in BST at two or more ipsilateral sites. When WS differentiated from NCV, a left-right difference ≥0.5°C in two or more ipsilateral sites had a sensitivity of 89% and specificity of 98%, and ≥1.0°C had a sensitivity of 78% and specificity of 98%. DISCUSSION: Acute WS can be differentiated from NCV through BST and the number of sites with lateral differences via thermography, even in rooms where conditions are unregulated.

Oral Intake in the Complete Lateral Position as a Compensatory Method for a Patient with Severe Dysphagia: A Case Report.

Background: We report a patient with severe dysphagia who was successfully treated using our newly developed swallowing rehabilitation method involving a complete lateral position. Case: This case involved a 74-year-old male patient with dysphagia caused by multiple morbidities, including sarcopenia after panperitonitis, Wallenberg syndrome, and Lewy body dementia. We attempted oral feeding in the complete lateral position and observed that the bolus was moving as intended and was swallowed without penetration or aspiration. The patient achieved oral feeding using the complete lateral position, and his physical and cognitive functions improved. He was discharged home and continued feeding orally without alternative means for more than 5 years. Discussion: In the flat (complete) lateral position, the bolus flows and pools as far as possible from the airway opening of the pharynx. Using this method, gravity aids in preventing penetration and aspiration. Therefore, eating in the complete lateral position has immediate effects that are reproducible and not dependent on the cognitive function or motor skills of the patient or the assistance skills of the caregivers.

Intrinsic stenosing and occlusive pathologies of the vertebral artery: A narrative review.

Intrinsic pathologies of the vertebral arteries, such as atherosclerosis, dissection, fibromuscular dysplasia, radionecrosis and vasculitis, are important causes of vertebrobasilar insufficiency and cerebrovascular events. This review focuses on non-aneurysmal intrinsic stenosing and occlusive pathologies, covering their epidemiology, diagnosis, and treatment options. It also provides a detailed summary of key clinical presentations and syndromes, including an in-depth examination of lateral medullary syndrome, historically known as Wallenberg's syndrome, which is arguably the most emblematic condition resulting from vertebral artery involvement and is depicted in an illustrative cartoon.

Opalski syndrome, a rare variant of wallenberg syndrome, the first case reported from Pakistan: A case report.

Background: Wallenberg syndrome, also known as a lateral medullary syndrome, is a rare neurological condition caused by an infarction in the brainstem's lateral medulla. There are subtypes of Wallenberg syndrome with distinctive and atypical symptoms, such as Opalski syndrome. Case presentation: A 41-year-old hypertensive male arrived at the emergency department with abrupt onset of right-sided bodily weakness, vertigo, facial numbness, dysphagia, hoarseness of voice, and double vision. The neurological examination indicated right hemiparesis, right facial numbness, crossed sensory deficit, right limb ataxia, right uvulopalatal deviation, and vertical double vision. An MRI showed a lateral medullary infarct leading to the suspicion of the atypical lateral medullary syndrome. The patient was treated with physiotherapy and daily oral medications including aspirin, clopidogrel, atorvastatin, and Cap Risek. On follow-up 14 days later, the patient's condition had significantly improved. Conclusion: This case study demonstrates the significance of recognizing atypical variants of Wallenberg syndrome, such as Opalski syndrome, in order to provide a correct diagnosis and the most effective treatment. Our patient's condition improved as a result of the therapy measures used, however, people with Opalski syndrome may have a poor prognosis and require continuous monitoring.

Concordant GRADE-3 Truncal Ataxia and Ocular Laterodeviation in Acute Medullary Stroke.

Background: Severe truncal ataxia associated with an inability to sit up without assistance (STA grade 3) is frequent in patients with central acute vestibular syndrome (AVS) involving the brainstem or cerebellum. When these patients have nystagmus, central HINTS excludes peripheral lesions; however, additional localization and lateralization signs are helpful, not only to resolve the peripheral versus central vestibular lesion dilemma, but to zero in on a precise lesion localization/lateralization to the lateral medulla, the most common ischemic lesion localization associated with an initially false-negative stroke MRI. Methods: This is a study of AVS patients with additional inclusion criteria: grades 2 or 3 ataxia with an eventual diagnosis of medullary stroke (MS), either involving the lateral medulla (LMS) or the medial medulla (MMS), and horizontal (h) gaze paralysis was the main exclusion criteria. All patients sat on the side of the bed or stretcher, with assistance if needed. A general neurologic examination followed in the sitting position, the testing protocol included the head impulse, spontaneous nystagmus, and skew deviation (HINTS) tests, followed by observation of the effect of brief 3-5 sec eyelid closure on ocular position, and saccade and pursuit eye movement tests. If they could sit, the protocol included the ability to stand with a wide base, then a narrow base, the Romberg test, and tandem gait. Radiographic lesion localization and horizontal gaze deviation concluded the protocol. Results: A total of 34 patients met the entry criteria, 34 MS (13 in the lateral medulla, 12 previously described, and 1 new patient), and 1 new MMS. Among them, n = 10/12 had grade 3 ataxia, and 3 (1 new patient) had grade 2 ataxia. In addition, overt ocular laterodeviation (OLD) was present in thirteen of them (35.3%). All OLD patients had gaze deviation and ipsilateral saccade and truncal lateropulsion, 1 medial medulla stroke patient had grade 3 truncal contrapulsion and contralateral hemiparesis without OLD, n = 20/21 patients with LMS without OLD had grade 3 truncal ataxia, and 1 had grade 2 truncal ataxia. Discussion: AVS patients with severe truncal ataxia (inability to sit without assistance) potentially have brainstem, cerebellum, or subcortical lesions. All patients had central HINTS; however, simultaneous direction-concordant STA 3 and OLD provided greater lateral medulla localization specificity, affecting the ipsilateral medulla. Future work to explore a practical posterior circulation stroke scale that includes HINTS, STA, and OLD will potentially select cases for thrombolysis even in the event of initially false-negative imaging.

The Value of Interdisciplinary Collaboration in Lateral Medullary Syndrome Rehabilitation: A Case Report.

Wallenberg's syndrome, also known as lateral medullary syndrome (LMS), is a neurological condition resulting from damage to the lateral portion of the medulla oblongata. We present a case of a 64-year-old man with Wallenberg's syndrome who presented for acute rehabilitation after sustaining a cerebrovascular accident (CVA). As seen in our patient, common symptoms of LMS include difficulty swallowing, hoarseness, ipsilateral weakness, and ipsilateral loss of sensation or numbness. Although the prognosis following infarction is often good, dysfunction in swallowing is one of the key deficits that have a long-term impact on patient quality of life. We aim to emphasize the significance of the interdisciplinary approach to achieving favorable health outcomes in patients with LMS.

Food Stuck in the Throat in a Newly Diagnosed Diabetes Mellitus Patient: An Atypical Presentation of Wallenberg's Syndrome.

Wallenberg's syndrome, also known as posterior inferior cerebellar artery syndrome (lateral medullary syndrome), is known to be a common cause of posterior ischemic stroke syndromes in men in their 60s and may present with varied symptoms devoid of focal neurological signs making it easily missed as a differential of posterior ischemic strokes. It involves a stroke in the vertebral or posterior inferior cerebellar artery of the brainstem. In this case report, we critically examine the case of a 66-year-old man with newly diagnosed diabetes whose main presentation was dysphagia and unsteady gait. There was no motor or sensory examination finding in our patient, and the initial computed tomography of the brain was negative for any intracranial pathology leading to very low suspicion of stroke. However, given a high index of suspicion and a thorough oropharyngeal examination ruling out structural abnormality, magnetic resonance imaging of the brain revealed features suggestive of Wallenberg's syndrome. This case emphasizes careful consideration of posterior stroke syndrome when evaluating patients presenting with dysphagia without typical motor/sensory symptoms of cerebrovascular accident and the requirement of further imaging to support the diagnosis.

A Case of Paradoxical Cerebral Embolism Due to Pulmonary Arteriovenous Fistula Mimicking Vertebral Artery Dissection With Wallenberg Syndrome.

Pulmonary arteriovenous fistula (PAVF) leads to paradoxical cerebral embolism, which can be fatal if left untreated. We report a rare case of brainstem infarction with acute severe headache and Wallenberg syndrome caused by a PAVF mimicking vertebral artery (VA) dissection. A 40-year-old man presented with a sudden occipital headache accompanied by right hemisensory disturbance. Magnetic resonance imaging revealed left lateral medullary infarction and poor depiction of the left VA. However, it was clearly recanalized on day six, and there were no findings of VA dissection. Whole-body contrast-enhanced computed tomography (CT) revealed a PAVF in the right lung and a thrombus in the feeding artery. The patient was diagnosed with hereditary hemorrhagic telangiectasia due to recurrent epistaxis and peripheral vasodilation of the tongue. An anticoagulant was administered for preventing further ischemic stroke, and a follow-up CT confirmed the disappearance of the thrombus in three months. Thoracoscopic partial lung resection was performed five months after the onset, and no recurrence of ischemic stroke was observed.

Acute dysphagia: A rare initial symptom of lateral medullary syndrome: A case report.

Introduction and importance: A unique etiology of stroke, lateral medullary syndrome (LMS), is a consequence of posterior inferior cerebellar artery or vertebral artery thromboembolic conditions. LMS patients present particularly with ipsilateral hyperalgesia, ipsilateral ataxia, and Horner's syndrome. Our case signifies that neurogenic origin should always be considered in the absence of local causes of dysphagia. Early diagnosis could prevent LMS complications, including neurological disabilities. A scarcity of research related to dysphagia in LMS, and its outcomes exists. Therefore, the objective is to investigate the clinical course in a patient afflicted with severe dysphagia following a diagnosis of (LMS). This would encourage further research, thus improving management and treatment strategies. Case presentation: We report a case of a 45-year-old male, a smoker for 20 years, who presented with a single, unique complaint of acute dysphagia for 9 days. According to our knowledge, this is among very few reported cases of LMS with dysphagia being the rare initial complaint. The neurological issues associated with dysphagia gradually improved with the administration of antiplatelet; clopidogrel and lipid-lowering drug; rosuvastatin and the patient was discharged. Atypical presentation in LMS could be supported by the presence of lateral medullary infarct which was confirmed by MRI (Magnetic Resonance Imaging). Clinical discussion: Dysphagia is a common complaint in multiple gastrointestinal (GI) settings. However, in cases where the GI causes are excluded, as described here, diagnosis of LMS becomes tough. Conclusion: The diagnosis of LMS was queried owing to the presentation of the single most important common symptom, with no other characteristic manifestations of LMS.

Lateral Medullary Syndrome Due to a Hypoplastic Vertebral Artery.

Vertebral artery hypoplasia is an uncommon congenital anatomical variation. Currently, no standard criteria exist for evaluating vertebral arteries as being hypoplastic based on vessel luminal diameter or volume flow. There is debate on the clinical significance of these variants and their relevance as an independent risk factor for posterior circulation strokes. We report a case of a 59-year-old male presenting with lateral medullary syndrome in the setting of a left hypoplastic vertebral artery with absence of atherosclerotic or thrombotic involvement.

Incidental finding of left vertebral artery agenesis: Case report.

Vertebral artery agenesis is a rare congenital malformation, with few reported cases in the literature and no epidemiological data in the world at this point in time. The importance of diagnosis lies in identifying a potential risk factor for future ischemic events of the posterior circulation, in particular in the young population. It is also important to determine the etiology of chronic headache of unexplained cause that could be attributed to this entity. The present case describes this finding in a 27-year-old female patient with no pathological history, with multiple stab wounds was brought to the emergency room of our hospital .During the study of whether the wounds caused had been penetrating to the neck, a CT angiography was performed. The CT documented an incidental finding of absent left transverse foramen of the cervical vertebrae, absence of the left vertebral artery from its origin in the ipsilateral subclavian artery and a single dolichoectatic right vertebral artery crossing the midline at the entrance to the foramen magnum.

Ocular contrapulsion followed by ipsipulsion in Wallenberg syndrome: The first case report in literature.

Wallenberg syndrome is also called lateral medullary syndrome, a neurological disorder resulting from occlusion of the vertebral artery or the posterior inferior cerebellar artery. The clinical presentations are associated with a variety of indications, including vestibulocerebellar symptoms, autonomic dysfunction and ipsilateral cerebellar signs. The ipsipulsion, an abnormality of the ocular movement associated with the Wallenberg syndrome, is more specific to the lateral medullary syndrome and is characterized by a tonic deviation of the eyes in the direction of the damaged side, more prominently when the visual fixation is interrupted. A 51-year-old male patient presented with a sudden permanent rotatory dizziness, unsteady gait, numbness in the left hemibody, left palate paresis, incoordination on left side and horizontal jerk nystagmus with left fast fase. Magnetic resonance imaging showed infarction in the left medulla and cerebellar. The ocular exam revealed saccadic lateropulsion ipsilateral to lesion. In the neurologic evaluation of the patient with Wallenberg syndrome, numerous abnormalities manifestations are present, such as vestibulo-ocular reflex deficiency, saccadic abnormalities, low pursuance movements and gaze fixation, and eye alignment dysfunction. This semiologic feature had not been described in literature until now. We hypothesize that an initial vasogenic edema extending to the left medial medulla following the acute stroke could explain the early presentation with saccadic counterpulsion. After one week and regression of the edema, the finding of lateropulsion has alternated to the classic ipsipulsion related to Wallenberg syndrome. The following case report depicts a rare case of Wallenberg syndrome associated with alterations of the ocular motricity.

Area postrema syndrome caused by medullary infarction.

In the present study, we report a case of persistent intractable nausea and vomiting after a medullary infarction. Area postrema syndrome due to ischemic stroke is very rare. In this case, brain magnetic resonance imaging revealed an ischemic lesion in the lateral medulla extending caudally and dorsomedially. The patient presented with sustained nausea, vomiting, and poor oral intake over one month after the index stroke, even after resolution of dizziness and disappearance of nystagmus. She did not respond to intravenous metoclopramide with ondansetron. However, their intractable nausea and vomiting eventually resolved with concomitant use of domperidone and itopride orally in addition to intravenous metoclopramide with ondansetron.

Late Diagnosis of a Patient With Gradual Onset of Lateral Medullary Syndrome Secondary to Spontaneous Vertebral Artery Dissection: A Case Report.

Lateral medullary syndrome (LMS), also known as Wallenberg syndrome, is a cerebrovascular event following ischemia of the lateral part of the medulla oblongata. Some of its etiologies include atherosclerotic changes, hypertension, thromboembolism, vertebral artery dissection (VAD), and aneurysm. We present a case of a 45-year-old male with LMS with a gradual onset of atypical symptoms of LMS, which has led to a late diagnosis of our patient. VAD is a commonly recognized cause of stroke in young people and it is a more frequent cause of LMS than posterior inferior cerebellar artery diseases. This case highlights the importance of early identification of signs and symptoms and that appropriate investigation should take place to optimize patient life quality and prognosis.