Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

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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
contralateral trunk/extremities should raise concern for the possibility of posterior circulation CVA or Wallenberg syndrome.
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