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ED Bounceback: A Rare Case Of Wallenberg Syndrome
McNamee, J, D.O. and Patel, N, D.O.
St. Joseph’s Regional Medical Center, Emergency Department, Paterson, NJ
Introduction: Wallenberg syndrome, also known as lateral medullary syndrome, has
been described in the literature for over a century, but is a rare form of stroke on the
spectrum of cerebrovascular accidents (CVA). The circulation involved in Wallenberg
syndrome affects the vestibular system thus leading to the common presenting
symptoms of nausea, vomiting, and vertigo. Our patient presented to the ED with
dizziness for the second consecutive day and on physical examination was determined
to have a central cause of her vertigo as opposed to a peripheral etiology. On admission,
an MRI confirmed our suspicion with visualization of a lateral medullary infarct
secondary to thrombosis of the left posterior inferior cerebellar artery (PICA).
Case: A 49 year old female with a PMHX of IDDM and hypertension presented to the
ED with a 2 day history of hypertension and dizziness. Patient described the dizziness
as the “room spinning”. Patient denied focal neurological deficits, dysarthria, dysphagia,
tinnitus, ear fullness, hearing loss, or otalgia. Positional changes did not exacerbate or
alleviate the symptoms. Initial set of vitals; T: 97.3° F , BP: 144/75, P: 108, RR: 22, 100%
RA. Her physical exam was unremarkable except for decreased sensation to the left
side of her face and right upper extremity along with mild dysmetria with finger to nose
testing on the left. Patient did not demonstrate any abnormalities with head impulse
testing, test of skew, rapid alternating movements, or heel to shin. Patient demonstrated
physiologic horizontal nystagmus and no vertical nystagmus. Lab results were within
normal limits and EKG showed sinus tachycardia and diffuse T wave flattening. Patient
had CT Head without contrast during ED visit, which revealed mild atrophy and old
lacunae in the left cerebellum. Neurologist admitted the patient for further work-up. She
had an MRI of Brain performed upon admission, which was positive for a lateral
medullary infarct secondary to thrombosis of the left posterior inferior cerebellar artery
(PICA). This was consistent with a Wallenberg syndrome. Patient’s hypercoagulable
work up and transesophageal echocardiogram were within normal limits. Patient’s
symptoms improved with physical and occupational therapy allowing her to be
discharged home on hospital day 4 with only mild deficits.
Discussion: It is important for the medical provider to differentiate between peripheral
vertigo and central vertigo. This begins with a thorough history and ends with the most
important part of the patient visit, the physical examination. In 2009, Stroke published a
landmark article about the “HINTS” neurological examination, which can be used to help
differentiate central from peripheral vertigo. HINTS exam includes head impulse,
nystagmus and test of skew. This bedside three step oculomotor examination is more
sensitive than MRI in early diagnosis of vestibular stroke according to a study by
Newman-Toker et al. in 2009. In order to prevent ED bouncebacks and more
importantly, further infarctions or secondary injuries related to neurological deficits from
CVA, clinicians must pay particular attention to detail when examining patients with the
complaints of “dizziness” or “vertigo.” Any abnormalities noted on cerebellar testing,
“HINTS” exam, or crossed sensory deficits affecting one side of the face and