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Q. ld : 4269 [
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6 A 56-year-old man comes to the emergency department with severe dizziness, inability to w alk, and stabbing
7 pain on the right side of his face that started this morning. He has a history of diet-controlled type 2 diabetes
mellitus, hypertension, and hyperlipidemia. His blood pressure is 144/90 mm Hg and pulse is 92/min. The
9 patient topples to the right when sitting without support. The left pupil is larger than the right, and there is
10 reduced corneal reflex on the right directly but not consensually. There is partial ptosis of the right eye.
11 Horizontal and rotational nystagmus is present. His gag reflex is diminished. There is loss of pain and
12 temperature sensation in the right face and the left trunk and limbs. Which of the following is the most likely
13 location of this patient's brain lesion?
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15
.~ A. Lateral cerebellar hemisphere [9%]
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17 .; B. Lateral medulla [37%]
18 C. Lateral mid-pons [29%]
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20 D. Medial medulla [11 %]
21 E. Medial mid-pons [ 14%]
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23
24 Explanation: User ld:
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26
?.7 Clinical features of Wallenberg syndrome

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19
20 • Vertigo, falling to the side of the lesion
21 Vestibulocerebellar • Difficulty sitting upright without support
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23 symptoms • Diplopia & nystagmus (horizontal & vertical)
24 • Ipsilateral limb ataxia
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26
?,7 . Abnormal facial sensation or pain (early
18 Sensory
19
symptom)
20 symptoms • loss of pain & temperature in ipsilateral face &
21 contralateral trunk & limbs
22
23
24 . Dysphagia &aspiration
25 Ipsilateral bulbar
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• Dysarthria, dysphonia &hoarseness (ipsilateral
muscle weakness
?.7 vocal cord paralysis)
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19
20 . Ipsilateral Horner's syndrome (miosis, ptosis &
21 anhidrosis)
22 Autonomic
23 • Intractable hiccups
24 dysfunction
. l ack of automatic respiration (especially
25
26 during sleep)
?,7
18 0 USMLEWorld, LLC

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This patient's presentation suggests right-sided lateral medullary infarction (Wallenberg syndrome) most likely
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due to an occluded intracranial vertebral artery. Vestibulocerebellar findings are almost always present
21
and include nystagmus (both horizontal and rotational), vertigo with falling to the side of the lesion, and
22
difficulty sitting upright without support. Sensory findings include loss of pain and temperature in the
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ipsilateral face (spinal trigeminal nucleus and tract) and contralateral trunk/limbs (spinothalamic tract).
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25 Other findings include ipsilateral bulbar muscle w eakness (eg, dysphagia, dysarthria) due to involvement of
26 the nucleus ambiguus and autonomic dysfunction (eg, ipsilateral Horner's syndrome). Patients typically
?.7 have sparing of voluntary motor function in the face and body. The diagnosis is made via magnetic resonance
18 imaging. Acute treatment usually involves intravenous thrombolytics (eg, tissue plasminogen activator).
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20 (Choice A) Lesions of the lateral cerebellar hemisphere present with minimal dizziness and ipsilateral
21 ataxia. They do not usually cause Horner's syndrome or loss of pain and temperature sensation.
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23 (Choice C) The pattern of cranial nerve involvement helps distinguish between lateral mid-pontine lesions
24 and those in the medulla. Lateral mid-pontine lesions affect the motor and principal sensory nuclei of the
25 ipsilateral trigeminal nerve, causing w eakness of the muscles of mastication, diminished jaw jerk reflex, and
26 impaired tactile and position sensation over the face. In contrast, dysphagia, hoarseness, and diminished gag
?,7 reflex are more typical of a lateral medullary infarct due to cranial nerve IX and X involvement.
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(Choice D) Medial medullary syndrome (alternating hypoglossal hemiplegia) is typically due to branch
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occlusion of the vertebral or anterior spinal artery. Patients develop contralateral paralysis of the arm and leg
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and tongue deviation tow ard the lesion. Contralateral loss of tactile and position sense can also occur with
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infarcts that extend dorsally.
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23 (Choice E) Medial mid-pontine infarction presents with contralateral ataxia and hemiparesis of the face,
24 trunk, and limbs (ie, ataxic hemiparesis). There is also variable loss of contralateral tactile and position sense.
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26 Educational objective:
27 Lateral medullary infarct (Wallenberg syndrome) occurs due to occlusion of the posterior inferior cerebellar or
28 vertebral artery. Patients develop loss of pain and temperature over the ipsilateral face and contralateral body,
29 ipsilateral bulbar muscle w eakness, vestibulocerebellar impairment (eg, vertigo, nystagmus), and Horner's
30 syndrome. Motor function of the face and body is typically spared.
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32 References:
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34 1. Traumatic vertebral artery dissection and Wallenberg syndrome after a motorcycle
35 collision.
36 2. Dysphagia caused by a lateral medullary infarction syndrome (Wallenberg's syndrome).
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Time Spent: 4 seconds Copyright © UW orld Last updated: [213/2015]
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 Media Exhibit

Vertebrobasilar system

Posterior brain circulation

Posterior
communicating Optic Internal
artery artery

Posterior
Basilar cerebral artery
artery

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cerebellar
artery (SCA)

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arteries

inferior
cerebellar
artery (AICA)

Posterior
inferior Intracranial
cerebellar vertebral
artery (PICA) Cerebellum artery (ICVA)
Spinal cord
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 Media Exhibit

Posterior circulation stroke syndromes

Medial medullary syndrome

 Media Exhibit

I
Posterior drculation stroke syndromes Medial medullary syndrome I

Medial medullary syndrome

Structure Sign

Medullar pyramid Contralateral hemiparesis

Contralateral loss of tactile,

Medial lemniscus
vibratory & position sense

Hypoglossal Ipsilateral tongue paralysis with

nucleus/fibers deviation to side of lesion

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 Media Exhibit

Posterior circulation stroke syndromes

Medial mid-pontine syndrome