History

Fact Explanation
Loss of pain and temperature sensations in one side of the face and body Damage to the spinal trigeminal nucleus causes ipsilateral facial sensory loss and damage to the spinothalamic tract causes contralateral body sensory loss.[1-7]
Facial pain Damage to the spinal trigeminal nucleus causes ipsilateral facial pain, which is constant, burning type and often aggravated by cold temperature and mechanical stimuli.[2,3,4]
Unsteadiness, dizziness Damage to the cerebellum or inferior cerebellar peduncle cause ataxia.[5,6,7]
Nausea and vomiting Damage to the Deiters' nucleus and other vestibular nuclei causes nausea and vomiting. [1,2,4,5,6]
Vertigo Damage to the Deiters' nucleus and other vestibular nuclei results in acute onset, severe vertigo. [1-7]
Hoarseness of voice Damage to the nucleus ambiguus (IXth and Xth cranial nerves), will make the voice hoarse.[2,3,4,5]
Difficulty in swallowing Damage to the nucleus ambiguus (IXth and Xth cranial nerves), causes weakness of palatal and pharyngeal muscles and causes dysphagia.[1-7]
Hiccups Though the exact underlying mechnism is unknown, hiccups are well documented symptom in Wallenberg syndrome.[3]
Slurred speech Damage to the nucleus ambiguus (IXth and Xth cranial nerves), results difficulty in articulation due to vocal cord dysfunction, making the speech slurred.[1,2,3]
Drooping of eye lid Damage to descending sympathetic fibers results in ipsilateral Horner syndrome.[2,4,5]
History of predisposing disease conditions - hypertension, hypercholesterolemia Most patients have a history of a disease conditions known to cause thrombosis, hemorrhage and atheresclerosis.[2,5,6]
Introduction In Wallerberg syndrome, which is also called Lateral medullary syndrome, there is dorsolateral infarction in the medulla, most often due to occlusion of the posterior inferior cerebellar artery [1-7]
References
  1. CASTILLO AL, BARAHONA-GARRIDO J, CRIALES S, CHANG-MENéNDEZ S, TORRE A. Wallenberg's Syndrome: An Unusual Case of Dysphagia. Case Rep Gastroenterol [online] 2007 Nov 9, 1(1):135-43 [viewed 09 September 2014] Available from: doi:10.1159/000110871
  2. KATO S, TAKIKAWA M, ISHIHARA S, YOKOYAMA A, KATO M. Pathologic reappraisal of wallenberg syndrome: a pathologic distribution study and analysis of literature. Yonago Acta Med [online] 2014 Mar, 57(1):1-14 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25067873
  3. SAMPATH V, GOWDA MR, VINAY HR, PREETHI S. Persistent hiccups (singultus) as the presenting symptom of lateral medullary syndrome. Indian J Psychol Med [online] 2014 Jul, 36(3):341-3 [viewed 09 September 2014] Available from: doi:10.4103/0253-7176.135397
  4. UEDA M, NISHIYAMA Y, ABE A, KATAYAMA Y. Hemorrhagic Wallenberg syndrome. Intern Med [online] 2013, 52(20):2383-4 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24126409
  5. PEARCE JM. Wallenberg's syndrome. J Neurol Neurosurg Psychiatry [online] 2000 May, 68(5):570 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10766884
  6. JAIN SK, GUPTA AK, AGARWAL N. Wallenberg's lateral medullary syndrome. Postgrad Med J [online] 2002 Oct, 78(924):618 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12415087
  7. KIM JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain [online] 2003 Aug, 126(Pt 8):1864-72 [viewed 09 September 2014] Available from: doi:10.1093/brain/awg169

Examination

Fact Explanation
Ipsilateral sensory loss (pain and temperature) in the face In Wallerberg syndrome, which is also called Lateral medullary syndrome, there is dorsolateral infarction in the medulla. Damage to the spinal trigeminal nucleus of Vth cranial nerve causes ipsilateral facial sensory loss.[1-5]
Contralateral hemisensory loss (pain and temperature) Damage to the anterior spinothalamic tract, at the level of medulla causes contralateral body sensory loss.[1-5]
Ataxic gait (ipsilateral) Damage to the cerebellum or the inferior cerebellar peduncle cause ipsilateral ataxic gait.[1-5]
Nystagmus (ipsilateral) Damage to the Deiters' nucleus and other vestibular nuclei results ipsilateral eye movement disorder known as nystagmus.[1-5]
Dysarthria and dysphonia Damage to the nucleus ambiguus (IXth and Xth cranial nerves), results difficulty in articulation due to vocal cord dysfunction.[1,2,3]
Ipsilateral Horner syndrome (ptosis, miosis, & anhydrosis) Damage to descending sympathetic fibers results in ipsilateral Horner syndrome.[1,2,3]
Ipsilateral absent gag reflex Damage to the nucleus ambiguus (IXth and Xth cranial nerves), causes weakness of palatal and pharyngeal muscles and causes weak/absent gag reflex.[2,4,5]
Ipsilateral reduced/absent corneal reflex Damage to the descending spinal nerve fibers and nucleus of Vth cranial nerve manifest as reduced/absent corneal reflex.[4.5]
Palatal myoclonus Damage to the central tegmental tract will give rise to involuntary, jerky movements in the palate.[2,4,5]
Dysmetria (past pointing) Due to damage to the cerebellum or the inferior cerebellar peduncle.[1-5]
Dysdiadokokinesia Due to damage to the cerebellum or the inferior cerebellar peduncle.[1-5]
Loss of taste sensation Loss of taste sensation in the posterior third of the tongue is due to damage to the nuclei or fibers of IXth and Xth cranial nerves.[3,4,5]
Tachycardia and dyspnea As a result of damage to the dorsal nucleus of Xth cranial nerve.[2,4,5]
References
  1. CASTILLO AL, BARAHONA-GARRIDO J, CRIALES S, CHANG-MENéNDEZ S, TORRE A. Wallenberg's Syndrome: An Unusual Case of Dysphagia. Case Rep Gastroenterol [online] 2007 Nov 9, 1(1):135-43 [viewed 09 September 2014] Available from: doi:10.1159/000110871
  2. KATO S, TAKIKAWA M, ISHIHARA S, YOKOYAMA A, KATO M. Pathologic reappraisal of wallenberg syndrome: a pathologic distribution study and analysis of literature. Yonago Acta Med [online] 2014 Mar, 57(1):1-14 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25067873
  3. PEARCE JM. Wallenberg's syndrome. J Neurol Neurosurg Psychiatry [online] 2000 May, 68(5):570 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10766884
  4. JAIN SK, GUPTA AK, AGARWAL N. Wallenberg's lateral medullary syndrome. Postgrad Med J [online] 2002 Oct, 78(924):618 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12415087
  5. KIM JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain [online] 2003 Aug, 126(Pt 8):1864-72 [viewed 09 September 2014] Available from: doi:10.1093/brain/awg169

Differential Diagnoses

Fact Explanation
Lateral pontine syndrome Characteristic findings in lateral pontine syndrome which help differentiating from Wallernberg syndrome include ipsilateral lower motor neuron type paralysis of facial muscles, ipsilateral loss of lacrimation and reduced salivation, ipsilateral loss of taste from the anterior two-thirds of the tongue.[1,5]
Medial medullary syndrome In medial medullary syndrome, trigeminal nucleus is saved, preserving the facial sensation.[1,3,5]
Weber's syndrome Occurs as a result of midbrain infarction and characteristic findings are oculomotor nerve palsy and contralateral hemiparesis or hemiplegia.[1,5]
Benedikt syndrome Oculomotor nerve palsy help differentiating from Wallenberg syndrome.[5]
Metastatic disease of the brain Suspect in patients with a history of primary tumor elsewhere in the body.[2,5]
Cerebellopontine angle tumors Radiological imaging modalities will help differentiating from Wallenberg syndrome.[2,4,5]
Giant cell arteritis Consider when the patient is complaining facial pain with tenderness over the temporal artery as the main symptom.[4]
References
  1. CASTILLO AL, BARAHONA-GARRIDO J, CRIALES S, CHANG-MENéNDEZ S, TORRE A. Wallenberg's Syndrome: An Unusual Case of Dysphagia. Case Rep Gastroenterol [online] 2007 Nov 9, 1(1):135-43 [viewed 09 September 2014] Available from: doi:10.1159/000110871
  2. JAIN SK, GUPTA AK, AGARWAL N. Wallenberg's lateral medullary syndrome. Postgrad Med J [online] 2002 Oct, 78(924):618 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12415087
  3. KIM JS, CHOI-KWON S. Sensory sequelae of medullary infarction: differences between lateral and medial medullary syndrome. Stroke [online] 1999 Dec, 30(12):2697-703 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10583000
  4. SHANAHAN EM, HUTCHINSON M, HANLEY SD, BRESNIHAN B. Giant cell arteritis presenting as lateral medullary syndrome. Rheumatology (Oxford) [online] 1999 Feb, 38(2):188-9 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10342638
  5. BALAMI JS, CHEN RL, BUCHAN AM. Stroke syndromes and clinical management. QJM [online] 2013 Jul, 106(7):607-15 [viewed 09 September 2014] Available from: doi:10.1093/qjmed/hct057

Investigations - for Diagnosis

Fact Explanation
Full blood count To assess the hemoglobin level, platelet count and white blood cell indexes.[1,2,3]
Clotting profile If suspecting inherited or acquired clotting problem, clotting profile tests should be done as baseline investigation.[1,2,3]
Lipid profile To identify undiagnosed dyslipidemias.[1,2,3]
Lupus anticoagulant and anticardiolipin antibodies If suspecting antiphospholipid syndrome as the cause of thrombosis, these investigations should be carried out.[2,3]
Protein C, protein S, and antithrombin III deficiencies, Factor V Leiden mutation Should be done only when there is a suspicion of a underlying thrombophilic condition.[2,3,4]
Magnetic resonance imaging (MRI) MRI found to be more sensitive compared to computed tomogrphy as it can identify early ischemic infarctions.[1,2,3,4]
Computed tomography (CT) Usually carried out as the first imaging study, because it is readily available and easy to perform. Also can identify brain hemorrhages.[2,3]
Angiography Useful to identify the anatomy of occluded blood vessels.[3,4]
Transcranial Doppler (TCD) Performed to evaluate cerebrovascular disease, but it often found to be inaccurate.[2,3]
References
  1. KATO S, TAKIKAWA M, ISHIHARA S, YOKOYAMA A, KATO M. Pathologic reappraisal of wallenberg syndrome: a pathologic distribution study and analysis of literature. Yonago Acta Med [online] 2014 Mar, 57(1):1-14 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25067873
  2. BALAMI JS, CHEN RL, BUCHAN AM. Stroke syndromes and clinical management. QJM [online] 2013 Jul, 106(7):607-15 [viewed 09 September 2014] Available from: doi:10.1093/qjmed/hct057
  3. KIM JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain [online] 2003 Aug, 126(Pt 8):1864-72 [viewed 09 September 2014] Available from: doi:10.1093/brain/awg169
  4. ROSS MA, BILLER J, ADAMS HP JR, DUNN V. Magnetic resonance imaging in Wallenberg's lateral medullary syndrome. Stroke [online] 1986 May-Jun, 17(3):542-5 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3715957

Investigations - Followup

Fact Explanation
International normalized ratio (INR) In patients with a known, documented source of cardio-embolism, (atrial fibrillation), warfarin should be started while maintaining an INR of 2-3.[1]
References
  1. BALAMI JS, CHEN RL, BUCHAN AM. Stroke syndromes and clinical management. QJM [online] 2013 Jul, 106(7):607-15 [viewed 09 September 2014] Available from: doi:10.1093/qjmed/hct057

Management - General Measures

Fact Explanation
Patient and family education It is important to educate the patient and the family members regarding the nature of the disease, complications that may occur, prognosis, plan of management to achieve a good compliance in rehabilitation programme.[1,2,3]
Symptomatic managment - Swallowing/feeding Impaired swallowing should be managed using a feeding tube or by performing a gastrostomy, to prevent aspiration pneumonia and to maintain adequate nutrient supply.[1,3]
Rehabilitation - Swallowing/feeding, Speech, Gait Rehabilitation plays a major role in sroke management as it aid patients to be independent as much as possible.[1,2,3]
Management of psychological aspects Neuropsychological evaluation is recommended to screen for depression, coping skills, family dysfunction and subtle cognitive, memory, or processing deficits. These affect future participation in and compliance with rehabilitation.[1]
Risk factor management Other medications may be necessary in order to suppress high blood pressure and other risk factors associated with strokes.[1]
References
  1. BALAMI JS, CHEN RL, BUCHAN AM. Stroke syndromes and clinical management. QJM [online] 2013 Jul, 106(7):607-15 [viewed 09 September 2014] Available from: doi:10.1093/qjmed/hct057
  2. NA EH, YOON TS, HAN SJ. Improvement of quiet standing balance in patients with wallenberg syndrome after rehabilitation. Ann Rehabil Med [online] 2011 Dec, 35(6):791-7 [viewed 09 September 2014] Available from: doi:10.5535/arm.2011.35.6.791
  3. KATOH J, HAYAKAWA M, ISHIHARA K, KAZUMI T. [Swallowing rehabilitation using balloon catheter treatment evaluated by videofluorography in an elderly patient with Wallenberg's syndrome]. Nihon Ronen Igakkai Zasshi [online] 2000 Jun, 37(6):490-4 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10998932

Management - Specific Treatments

Fact Explanation
Acute stage management In every patient, air way patency with protection of the cervical spine, breathing and circulation have to be assessed immediately and measured should be taken to resuscitate.[1,3]
Pain management Patients who complain pain should be treated according to the analgesics ladder. Gabapentin can be used for those who have got severe neuropathic pain.[1]
Management of hiccups Depending on the severity of the blockage caused by the stroke, the hiccups can last for weeks. Unfortunately there are very few treatment options available to relieve the inconvenience of constant hiccups.[1]
Thrombolysis Tissue plasminogen activator (tPA) can be used within 3- to 4.5-hours onset of the ischemic stroke.[1]
Long term management Involves the use of antiplatelets like aspirin or clopidogrel and statin regimen for the rest of their lives in order to minimize the risk of another stroke. Warfarin is used if atrial fibrillation is present.[1]
Management of complications Potential complications such as aspiration pneumonia, deep venous thrombosis, pulmonary embolism and myocardial infarction should anticipated, detect early and treat accordingly.[1,2,3]
References
  1. BALAMI JS, CHEN RL, BUCHAN AM. Stroke syndromes and clinical management. QJM [online] 2013 Jul, 106(7):607-15 [viewed 09 September 2014] Available from: doi:10.1093/qjmed/hct057
  2. NA EH, YOON TS, HAN SJ. Improvement of quiet standing balance in patients with wallenberg syndrome after rehabilitation. Ann Rehabil Med [online] 2011 Dec, 35(6):791-7 [viewed 09 September 2014] Available from: doi:10.5535/arm.2011.35.6.791
  3. KATOH J, HAYAKAWA M, ISHIHARA K, KAZUMI T. [Swallowing rehabilitation using balloon catheter treatment evaluated by videofluorography in an elderly patient with Wallenberg's syndrome]. Nihon Ronen Igakkai Zasshi [online] 2000 Jun, 37(6):490-4 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10998932