Wallenberg syndrome

Zhenisa Hysenaj, MD , Razia Rehmani MD

Key Points:

  • Lateral medullary syndrome is most commonly due to occlusion of the intracranial portion of the vertebral artery followed by PICA and its branches.
  • 20% of ischemic strokes occur in the posterior circulation
  • Hypertension is the most common risk factor
  • Clinical presentation can be attributed to the following:
    Vestibulo-cerebellar symptoms: vertigo, diplopia, and multidirectional nystagmus
    Autonomic dysfunction: Ipsilateral Horner’s syndrome. Hoarseness, dysphonia, dysphagia, and dysarthria
  • Best diagnostic test is MRI
  • The most common sequela is gait instability[1]

 

Discussion.

Wallenberg syndrome was first described by Adolf Wallenberg in 1895 based on the clinical presentation of a live case of lateral medulla oblongata (MO) infarct. He performed a pathological analysis on the same patient’s autopsy in 1901, reporting the detailed pathology for the same. After 1901, this disease was called Wallenberg syndrome[2]. However, it is most commonly caused due to occlusion of the vertebral artery followed by PICA.

Wallenberg syndrome is the most prevalent posterior ischemic stroke syndrome. 20% of the ischemic strokes occur in the posterior circulation[3]. The most common causes of posterior circulation arterial disease are atherosclerosis, embolism, and dissection.

Lateral medullary (or Wallenberg’s) syndrome may clinically present with vertigo, diplopia, dysarthria, Horner`s syndrome, numbness (ipsilateral face and contralateral limb) and traditionally it is not associated with any limb weakness. Characteristic clinical presentation, exclusive blood supply and very small area of involvement[4] can help localizing the site of the lesion.

While lateral medullary syndrome remains a clinical diagnosis based upon a characteristic history and constellation of physical findings, MRI offers definitive diagnosis by showing diffusion restriction in the ventrolateral medulla. In addition, MRI can demonstrate coexisting cerebellar infarction that may have been previously clinically unsuspected and undetected by CT[5].

Overall Wallenberg syndrome has a better functional outcome than most other stroke syndromes. Most patients can return to satisfactory activities of daily living. The most common sequela is gait instability[1].

As such an initial balance control assessment by posturography is recommended for patients with Wallenberg syndrome. Early balance rehabilitation program based on their posturography results enables them to improve their quality of life by balance training.[6]

 

References

  1. Lui, F., Tadi, P. & Anilkumar, A. C. Wallenberg Syndrome. in StatPearls (StatPearls Publishing, 2019).
  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. 57, 1–14 (2014).
  3. Lui, F., Tadi, P. & Anilkumar, A. C. Wallenberg Syndrome. in StatPearls (StatPearls Publishing, 2019).
  4. Pandey, S. & Batla, A. Opalski’s syndrome: A rare variant of lateral medullary syndrome. J. Neurosci. Rural Pract. 4, 102–104 (2013).
  5. Shetty, S. R., Anusha, R., Thomas, P. S. & Babu, S. G. Wallenberg’s syndrome. J. Neurosci. Rural Pract. 3, 100–102 (2012).
  6. Na, E. H., Yoon, T. S. & Han, S. J. Improvement of Quiet Standing Balance in Patients with Wallenberg Syndrome after Rehabilitation. Ann. Rehabil. Med. 35, 791–797 (2011).

Authors


Zhenisa Hysenaj, MD


PGY 2 Internal Medicine Resident
St Barnabas Health System
Bronx, NY


Razia Rehmani, MD


Chief of Neuroradiology & Musculoskeletal Imaging
Diagnostic Radiology
St Barnabas Health System
Bronx, New York