Lateral Medullary Syndrome: Uncommon Form of Brainstem Stroke

doi:10.21203/rs.3.rs-2109511/v1

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Case Report

Lateral Medullary Syndrome: Uncommon Form of Brainstem Stroke

https://doi.org/10.21203/rs.3.rs-2109511/v1

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Introduction and importance:

Lateral medullary syndrome (LMS) is less common form of brainstem stroke. It is the result of occlusion of posterior inferior cerebellar artery (PICA). It is caused by atherosclerosis, thrombosis or emboli from another source.

Case Presentation:

A 60-year-old male patient presented to the emergency department with vertigo, vomiting, slurred speech, hiccups, and right side weakness associated with parasthesia for one day. He had past medical history of uncontrolled hypertension, and a smoking habit. The neurological examination revealed ataxia, right hemiparesis associated with parasthesia. Cranial nerve examination revealed right-sided slight ptosis, mouth deviation, and loss of sensory sensation on the right side of the face. Brain MRI showed right medullary infract consistent with lateral medullary syndrome. Electrocardiogram, echocardiography and vertebral artery color Doppler were normal. He was admitted to the neurology ward and was treated with Clexane 60mg SC, Aspirin 300 mg, neuroprotective agents, and antihypertensive treatment. After 6 days of medical treatment, his condition has improved massively (dysarthria and dysphagia disappeared). He was discharged for physical rehabilitation.

Clinical discussion:

Lateral medullary syndrome (Wallenberg syndrome) is one of the brainstem stroke syndrome caused by occlusion of PICA. Vertigo, vomiting, dysphagia, dysarthria, ipsilateral ataxia, Horner syndrome and contralateral hemiparesis define this syndrome. Brain MRI is necessary for diagnosis alongside the clinical syndrome.

Conclusion

LMS is rare form of brainstem stroke and carries favorable prognosis if early hospitalization and treatment is applied. Brain MRI including diffusion sequence is the most useful diagnostic tool for detecting LMS.

Neurology

Lateral Medullary Syndrome

Brainstem Stroke

PICA

In 1808 Gaspard vieussux first reported the Lateral medullary syndrome. It was 1895 and 1905 when Wallenberg described this syndrome in detail via clinically and via autopsy ^[1]. Lateral medullary syndrome (Wallenberg syndrome) is one of the less common forms of brainstem stroke syndromes caused by infarction of the dorsolateral medulla due to occlusion of the posterior inferior cerebellar artery, branch of vertebral artery^{[2, 3]}. Patients with the this syndrome present with crossed hemisensory/motor deficits (e.g. ipsilateral face, contralateral body), ipsilateral Horner syndrome, and vertigo, nausea, vomiting, ataxia, dysphagia, hiccups and dysarthria ^[4]. Some other associated less common neurological presentations include nystagmus, diplopia, and possibly palatal myoclonus ^[5]. Recognition of this syndrome is of particular importance due to some similarities with other brainstems strokes. Brain MRI including diffusion sequence is the main stay of diagnosis of posterior circulation infarcts including lateral medullary syndrome ^{[6, 17]}. This syndrome has favorable prognosis if diagnosis and early treatment initiated ^[7]. Here, we present 60 year old male patient who was admitted to our neurology department due to lateral medullary infarction consistent with Wallenberg syndrome

A 60-year-old male patient presented to the emergency department with vertigo, vomiting, hiccups, ataxia and right side hemiparesis associated with parasthesia for one day. The patient also had slurred speech and dysphagia. He had a past medical history of uncontrolled hypertension, and using Khat (Catha Edulis) and cigarette smoking for 40 years.

On examination, the patient looks lethargic not oriented to time, place and person. His Glasgow coma scale was 9/15(Eye-3, Verbal 3, and Motor-3). On admission, his blood pressure of 156/85 mmHg and a pulse rate of 89 beats per minute. Other vital signs were unremarkable. The neurological examination revealed truncal ataxia, right side hemiparesis with power 4/5 associated with parasthesia. His speech was dysarthria, but comprehension was intact. He had moderate dysphagia. His palate was midline and not deviated. Coordination assessment with finger-to-nose and heel-to-shin testing revealed severe right-sided dysmetria. When sitting, the patient had marked truncal ataxia, with a tendency to fall to the right. All deep tendon reflexes (DTRs) and plantar reflexes were normal,.,

Cranial nerve examination revealed right-sided slight ptosis, mouth deviation, and loss of sensory sensation on the right side of the face. Other systemic examinations were unremarkable. Brain MRI diffusion showed right medullary infract consistent with Wallenberg syndrome (see Fig. 1). Electrocardiogram, echocardiography and chest x-ray showed normal. Carotid and vertebral artery color Doppler did not show any significant stenosis or narrowing.

Due to a delay in hospital arrival, the patient missed the golden hours of thrombolytic treatment with tissue plasminogen activator. He was admitted to the neurology ward and was treated with low molecular weight heparin 60mg SC, Aspirin 300 mg, and Amilodipine 10mg, and other neuroprotective agents. After 6 days of hospital treatment, his condition has improved massively (dysarthria and dysphagia almost disappeared). He was discharged for physical rehabilitation. On outpatient follow up 1month later, ataxia resolved and was on physical rehabilitation. This case has been reported in line with the SCARE 2020 criteria ^[18]

Lateral medullary syndrome is a rare form of ischemic stroke which is frequently caused by a thrombosis or embolism from the heart or large arteries ^[8]. Hemorrhage, dissection of the vertebral artery, cavernous angioma, and malignancies are additional causes of this disease ^[9].The majority of cases reported in stroke registries of LMS mentioned that vertebral artery dissection and large artery atherosclerosis are major risk ^[10,11]. İn younger pateints, vertebral artery dissection is most risk factor of LMS or those with a history of trauma, whereas adult patients atherosclerosis is the major risk factor more specifically hypertension, diabetes, and coronary artery disease ^[12,13]. Lateral medullary syndrome is the most frequent prevalent brainstem ischemic stroke syndromes, yet less common when compared to other forms of stroke. 75% of cases of LMS is large artery atherothrombotic where as 17% cardioembolic and remaining 8% is due to vertebral artery dissection ^[14].

LMS patients have a different of clinical presentations but, depending on the effected anatomic structure, such as, visual abnormalities, reduced pain and temperature sensations on the same side of face and contralateral body, ipsilateral hemiparesis, vertigo, ataxia, nausea and vomiting, a nasal voice, dysphonia, hoarseness, weakness, also there is absence of taste sensation, decreased gag reflex and dysphagia, and slurred speech.[15]. Our case had vertigo, vomiting, dysphagia, hiccups, ataxia, right side hemiparesis associated with parasthesia, slight ptosis, mouth deviation, and loss of sensory sensation on the right side of the face. In our approach to diagnosing this case, we did a perfect neurological examination. According to the patient, the neurological examination findings were consistent with lateral medullary syndrome, but in order to confirm it, we did diffusion brain MRI and showed righlt lateral medullary infarction.

According to current recommendations, all patients who present with LMS who came to emergency within 4.5 hours of the onset of symptoms should be given intravenous tissue plasminogen activator if there are no contraindications. Furthermore, for secondary prevention, anticoagulation, antiplatelete and risk factors control is required. ^[16]. The patient was not given tissue plasminogen activator due to delay of thrombolytic therapy period. He was admitted to the neurology ward and treated with low molecular weight heparin 0.6 SC, aspirin 300 mg, amlodipine 10 mg, and other neuroprotective agents. After a week of hospital treatment, his condition has improved massively (dysarthria and dysphagia almost disappeared). He was discharged for physical rehabilitation. On outpatient follow up 1month later, ataxia resolved and was on physical rehabilitation.

Identification of symptoms and signs associated with lateral medullary syndrome is crucial for the diagnosis of this syndrome. The outcome of patients with this syndrome is variable, and recovery may take several weeks or months following treatment. Early recognition and management is vital for better recovery. The current case had significant improvement after successful management.

Consent for publication: Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval: According to our hospital rule, Ethical approval is only required in articles but not case reports.

Author contribution: All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding: None

Conflict of interest: The authors declare no conflict of interest

Guarantor: Mohamed Sheikh Hassan, the corresponding author

Provenance and peer review: Not commissioned, externally peer-reviewed

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Version 1

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Lateral Medullary Syndrome: Uncommon Form of Brainstem Stroke

Status:

Version 1

Abstract

Introduction and importance:

Case Presentation:

Clinical discussion:

Conclusion

Figures

Introduction

Case Presentation

Discussion

Conclusion

Declarations

References

Status:

Version 1