![]() It is the most common form of all clinical posterior ischemic infarctions and arises predominantly in men during their sixth decade. Wallenberg syndrome, also known as lateral medullary syndrome or posterior inferior cerebellar artery syndrome, is a constellation of symptoms caused by posterior vascular accidents. The patient was started on antibiotics for his urinary tract infection, high-intensity statin therapy, low-dose aspirin therapy, and eventually discharged to subacute rehabilitation for further management once medically stabilized. In light of such a high suspicion for stroke based on the patient’s neurologic deficits, a repeat MRI of the brain was performed three days later and exposed a small focus of bright signal (hyperintensity) on T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) (Figure 3) and diffusion-weighted imaging (DWI) in the left posterior medulla (Figure 4). An initial magnetic resonance imaging (MRI) of the brain with and without contrast revealed no abnormality (Figures 1, 2). An echocardiogram was performed and showed a left ventricular ejection fraction of 65% to 70%, normal left ventricular size and systolic function, and no segmental wall motion abnormalities. A CT angiography (CTA) of the head and neck showed no significant stenosis, aneurysm, or vascular malformation. Urine culture grew Escherichia coli with a colony count greater than 100,000 CFU/mL and was susceptible to nitrofurantoin.Ī computed tomography (CT) scan of the head showed no acute intracranial pathology. Urinalysis revealed moderate leukocyte esterase, positive nitrites, and urine white blood cells greater than 50. Initial laboratory analysis was remarkable for an elevated creatinine of 1.4 mg/dL (normal 0.7-1.3 mg/dL), elevated troponin I high sensitivity of 54.20 ng/L (normal 0-53.53 ng/L), and thyroid-stimulating hormone of 0.14 uIU/mL (normal 0.55-4.78 uIU/mL). Vision tests were difficult to assess and compare as he had a severe right cataract. Physical examination showed decreased left arm and leg strength compared to the right side, decreased left facial temperature sensations, decreased left arm and leg temperature sensations, and difficulty sitting upright with an associated leaning towards the left side. The rest of the review of systems was unremarkable. He denied a prior history of stroke or myocardial infarction. The patient reported that he returned home from breakfast one day ago, sat on the front steps of his home, and suddenly felt dizzy and "passed out." It was unknown how long he lost consciousness as it was unwitnessed. Our patient is a 65-year-old male with a medical history of hypertension and hyperlipidemia, who was brought in by emergency medical services complaining of right-sided facial droop, slurred speech, and left-sided weakness of one-day duration. Early detection, management, and rehabilitation are critical for improving post-stroke recovery. Wallenberg syndrome has the potential to leave patients extremely debilitated. MRI with DWI is the gold standard to confirm the diagnosis. The neurological deficits associated with this disease are due to damage of the lateral medulla, inferior cerebellar peduncle, nucleus of trigeminal nerve, nucleus and fibers of vagus and glossopharyngeal nerves, descending sympathetic tract, spinothalamic tract, and/or vestibular nuclei. In light of such a high suspicion for stroke based on the patient’s neurologic deficits, a repeat MRI of the brain was performed three days later and exposed a small focus of bright signal (hyperintensity) on T2-weighted fluid-attenuated inversion recovery and diffusion-weighted imaging (DWI) in the left posterior medulla. An initial magnetic resonance imaging (MRI) of the brain with and without contrast revealed no abnormality. Our patient is a 65-year-old male who was brought in by emergency medical services complaining of right-sided facial droop, slurred speech, and left-sided weakness for one day. We present an atypical case of Wallenberg syndrome in which the initial MRI of the brain was normal. Diagnosis of Wallenberg syndrome is often overlooked as initial MRI may show no visible lesion. Wallenberg syndrome is the most common stroke of the posterior circulation. ![]()
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