A 34-Year-Old Woman With Headache, Dizziness, and Poor Coordination

A 34-year-old woman presents to the emergency department (ED) with a 3-day history of pain around the right ear extending to the temple. She was sitting at work today when she suddenly experienced dizziness, a feeling of discomfort in the throat, and a burning sensation in the left arm and leg. When she tried to stand and walk, her right arm and leg did not move in a normal, coordinated manner. The patient was previously healthy and does not take any regular medications. She does not smoke or drink. She does vigorous aerobic exercises on an almost daily basis. Her mother and a number of relatives on her mother's side suffer from hypertension. On physical examination, the patient has an oral temperature of 98.6F (37.0C). Her pulse is regular with a rate of 86 bpm. Her blood pressure is 164/90 mm Hg, and her heart sounds are normal and without added sounds. There are no arterial bruits auscultated in her neck. She is noted to have prolonged bouts of hiccuping. She is unable to stand due to a severe feeling of imbalance. There is right-sided ptosis and miosis. She has a sustained horizontal gaze-evoked nystagmus looking to the left and right, with a downbeating nystagmus on downward gaze. There is decreased sensation of pinprick and temperature on the right side of the face. On the right side there is also reduced movement of the palate, and the gag reflex is diminished. The tongue movements are normal. The power is normal in all 4 limbs, the deep tendon reflexes are normal, and the plantar responses are downgoing bilaterally (there is no Babinski sign). There is a moderate degree of ataxia affecting the right arm and leg. There is decreased sensation to pinprick and temperature on the left arm, leg, and trunk. The joint position and vibration sense are intact bilaterally. Routine laboratory analysis, including a complete blood cell count, a basic metabolic panel, and a lipid profile, is normal. A noncontrast computed tomography (CT) scan of the head is normal. Magnetic resonance imaging (MRI) of the brain is obtained (Figure 1).

What is the diagnosis? Hint: Consider the cranial nerves involved, and which sensory modalities are affected. Right-sided lateral pontine stroke (ie. Marie-Foix syndrome) Right-sided lateral medullary stroke (ie, Wallenberg syndrome) Right-sided medial medullary stroke (ie, Dejerine syndrome) Right-sided hemi-medullary stroke (ie, Babinski-Nageotte syndrome) Left-sided medial medullary stroke