Lateral Medullary Syndrome

Related Summaries

● Thrombolytics for acute stroke

● Swallowing dysfunction after stroke

● Cervical artery dissection

General Information

Description

● brainstem stroke syndrome with presentation of Horner's syndrome, ipsilateral ataxia, and crossed
pattern of numbness (ipsilateral facial numbness and contralateral limb numbness) with possible
accompanying dysphagia, vertigo, hiccups, and nystagmus 1

Also called

● Wallenberg syndrome

● Wallenberg stroke

● lateral medullary infarction

● syndrome of the posterior inferior cerebellar artery

Types

● lateral medullary syndrome can be complete or incomplete depending on extent of lesion 1

Epidemiology

Incidence/Prevalence

● lateral medullary syndrome accounts for

⚬ about 2.5% of cases of cerebral infarction 3

⚬ 3% of 955 patients with ischemic stroke admitted to a university medical center in Japan between

2007 and 2010 3

⚬ 1.9% of admissions for acute stroke, based on data from population-based stroke registry from
1982 to 1988 (Neurology 1991 Feb;41(2 (Pt 1)):244 )

Possible risk factors

● in cohort of 130 patients (mean age 57 years) with lateral medullary infarction 2

⚬ hypertension in 64%
⚬ diabetes mellitus in 25%
⚬ current cigarette use in 25%
⚬ atrial brillation in 5%
 ⚬ past history of coronary heart disease in 5%
⚬ past history of radiation therapy to neck in 2%

● other possible risk factors identi ed that occurred in < 10% of patients in series of 91 patients (mean
age 56 years) with proximal posterior circulation infarctions (including 26 with lateral medullary
syndrome)
⚬ peripheral vascular disease
⚬ alcohol use
⚬ drugs
⚬ migraine
⚬ coagulopathies
⚬ Reference - Eur Neurol 1997;37(3):157

● see also Risk factors for stroke or transient ischemic attack

Associated conditions

● cerebellar infarction 1

Etiology and Pathogenesis

Causes

● lateral medullary stroke can be caused by 1

⚬ thrombosis
⚬ embolism
⚬ syphilitic arteritis
⚬ bromuscular dysplasia
⚬ vertebral artery dissection

– spontaneous vertebral artery dissection

– vertebral artery trauma caused by

● chiropractic manipulation of neck

● yoga positions
● trauma to neck

● among 26 patients with lateral medullary infarction, most common cause of stroke was hemodynamic
changes from local occlusive disease of intracranial vertebral artery; cardiac embolism thought to be
cause in only 1 patient (Eur Neurol 1997;37(3):157 )

● case series and reports of lateral medullary syndrome caused by

⚬ aneurysms of anterior inferior cerebellar artery/posterior inferior cerebellar artery (AICA/PICA)

variant in 2 patients (Br J Neurosurg 2009;23(5):554 )
⚬ fusiform aneurysm of basilar artery secondary to neuro bromatosis type 1 (Intern Med 2001
Sep;40(9):948 )
⚬ brainstem tuberculoma (J Assoc Physicians India 2011 Jun;59:382 )
⚬ extradural location of posterior inferior cerebellar artery (PICA) (Neurol Sci 2011 Aug;32(4):711 )
⚬ PICA aneurysm in 4 patients (J Clin Neurosci 2000 Nov;7(6):515 )
 ⚬ Chiari malformation type I causing incomplete lateral medullary syndrome (J Neurosurg Pediatr
2008 Oct;2(4):250 )
⚬ neuro-Behcet disease (Eur J Neurol 2007 Jul;14(7):e16 )
⚬ hypoplastic vertebral artery in 3 adults aged 37-40 years (J Neurol Neurosurg Psychiatry 2007
Sep;78(9):987 full-text ), editorial can be found in J Neurol Neurosurg Psychiatry 2007
Sep;78(9):916
⚬ skull base osteomyelitis (Eur J Paediatr Neurol 2007 Mar;11(2):111 )
⚬ relapsing polychondritis (J Clin Rheumatol 2003 Apr;9(2):92 )
⚬ multiple sclerosis (MS) (J Clin Neurosci 2009 Dec;16(12):1700 )
⚬ penetrating head injury (J Clin Neurosci 2006 Aug;13(7):792 )
⚬ herpes simplex encephalitis (Acta Medica (Hradec Kralove) 2004;47(1):55 )
⚬ severe coughing (J Clin Neurosci 2004 Feb;11(2):179 )
⚬ left atrial myxoma (Optometry 2002 Nov;73(11):694 )
⚬ prone positioning for general surgery (Anesth Analg 2002 Nov;95(5):1451 full-text )
⚬ temporal arteritis (Rheumatology (Oxford) 1999 Feb;38(2):188 full-text )
⚬ plasma separation procedure (Nephrol Dial Transplant 1998 Dec;13(12):3261 )

Pathogenesis

● occlusion of vertebral artery or posterior inferior cerebellar artery (PICA) causing typical pattern of

infarction of dorsolateral medulla posterior to inferior olivary nucleus 1

● stroke usually caused by vertebral artery occlusion with or without extension to involve PICA and less
likely to be from occlusion of PICA alone (J Neuropathol Exp Neurol 1961 Jul;20:323 )

● isolated PICA stenosis or occlusion may be related to cardiogenic embolism and less often to
dissection compared to vertebral artery lesions in series of 130 patients with lateral medullary
infarction 2

● death may occur from

⚬ extension of infarction into ipsilateral inferior cerebellum with secondary herniation

⚬ involvement of dorsal motor nucleus of vagus nerve
⚬ bilateral lesions causing autonomic dysfunction
⚬ Reference - Neurology 1998 May;50(5):1418

History and Physical

History

Chief concern (CC)

● clinical presentation in patients with lateral medullary infarction

⚬ sensory symptoms (most common)

⚬ dysarthria
⚬ vertigo/dizziness
⚬ unsteadiness of gait
⚬ Horner's syndrome
⚬ trouble swallowing
 ⚬ hoarseness
⚬ incoordination of extremities
⚬ weakness
⚬ nausea and vomiting (may be severe)
⚬ headache

– can precede stroke

– location either ipsilateral occipital or frontal
– intensity mild to severe

⚬ double vision
⚬ facial paresis
⚬ change in sensorium
⚬ hiccups (reported to develop in 14% of series of 51 patients [J Neurol Neurosurg Psychiatry 2005
Jan;76(1):95 full-text ])
⚬ Reference - 2 , Stroke 2004 Mar;35(3):694 full-text

● additional symptoms may include 1

⚬ facial or extremity numbness

⚬ unsteadiness and falling

● presentation may be related to level of lesion in medulla 2

⚬ upper medulla

– dysphagia
– hoarseness
– weakness in face

⚬ lower medulla

– dizziness
– uncoordinated gait
– oscillopsia

History of present illness (HPI)

● transient ischemic attack (TIA) consisting of dizziness, headache, diplopia, staggering, may occur in

about half of patients days to weeks prior to stroke 1

● in series of 130 patients, onset reported to be either 2

⚬ sudden in 75%
⚬ stepwise or progressive in 25%

● ask about chiropractic manipulation of neck 1 , 2

● ask about extreme lateral motions of neck such as can occur during 1 , 2

⚬ yoga
⚬ golf swing

Physical

General physical
● may have hiccups 1 , 2

HEENT

● Horner's syndrome with ptosis and miosis (facial anhidrosis less common) 1 , 2

● nystagmus usually horizontal and rotatory 1 , 2

● skew deviation 2

● check for dysarthria and hoarseness 1 , 2

● gag re ex may be decreased 1

● ipsilateral loss of taste may be present 1

● review of oculomotor disorders occurring in vertebrobasilar syndromes can be found in Curr Opin
Neurol 2003 Feb;16(1):45

Neuro

● 1 of the "crossed" brainstem syndromes 1

⚬ crossed cranial nerve and long tract ndings

⚬ ipsilateral loss of pain and temperature sensation in face
⚬ contralateral loss of pain and temperature over body and extremities

● unusual sensory variants reported include

⚬ contralateral leg and lower trunk with ipsilateral lower face hypalgesia
⚬ contralateral upper trunk, arm, and face hypalgesia
⚬ contralateral hypalgesia with facial sparing
⚬ hemibody sensory loss
⚬ contralateral leg and lower trunk hypalgesia with facial sparing
⚬ Reference - J Neurol Neurosurg Psychiatry 1999 May;66(5):691 full-text

● ataxia of ipsilateral limbs with falling toward the side of lesion 1 , 2

● facial weakness may be present 1 , 2

Diagnosis

Making the diagnosis

● may be di cult to diagnose clinically as spectrum of symptoms may vary 1

● typical clinical presentation of Horner's syndrome, ataxia, alternating sensory symptoms, nystagmus,

hoarseness, and vertigo 1

● infarction con rmed by magnetic resonance imaging (MRI) 1

● lesion usually missed on computed tomography (CT) 1

Differential diagnosis

● other posterior circulation strokes

● medial medullary syndrome 1

● hemimedullary syndrome (Babinski-Nageotte syndrome) 1

● case report presentations similar to lateral medullary syndrome

⚬ basilar migraine in 42-year-old woman (Acta Neurol Taiwan 2010 Dec;19(4):275 PDF )
⚬ Brown-Sequard syndrome in 65-year-old woman (Acta Neurol Taiwan 2010 Sep;19(3):204 PDF
)

Testing overview

● magnetic resonance imaging (MRI)

● swallowing evaluation should be done before starting any oral intake (AHA/ASA Class I, Level B, CSBPR
Evidence Level B, SIGN Grade C)

Imaging studies

● diagnosis can be con rmed on magnetic resonance imaging (MRI) 1

● di usion-weighted magnetic resonance images (DWI) were positive in 12 of 13 patients with acute (<
48 hours) or subacute (between 3 and 11 days) stages of lateral medullary syndrome (Acta Radiol
2004 Feb;45(1):78 )

● MRI is preferred over computed tomography (CT), for identifying brainstem infarctions

⚬ advantages of MRI

– lack of bony artifacts

– high spatial resolution
– sharp contrast can be seen between normal tissue and lesions

⚬ in series of 33 patients with lateral medullary syndrome

– 33 patients had CT imaging with normal posterior fossa in 91% and abnormal posterior fossa
(cerebellar infarction) in 9%
– 22 patients had MRI with normal posterior fossa in 9% and abnormal posterior fossa in 91%
– among 20 patients with abnormal posterior fossa on MRI

● lateral medullary infarct alone in 12 patients

● other brainstem infarct with or without lateral medullary infarction in 8 patients

⚬ Reference - Arch Neurol 1993 Jun;50(6):609

● conventional angiogram or magnetic resonance angiography (MRA) can identify blood vessel

involved 2
⚬ documented lesions in 123 patients who had angiography (conventional angiogram in 52 and MRA
in 71)
 – vertebral artery in 67%
– posterior inferior cerebellar artery (PICA) in 10%

⚬ large vessel infarction in 50%

⚬ dissection in 15%

● noninvasive duplex Doppler studies may detect disease of vertebral artery in series of 33 patients
(Arch Neurol 1993 Jun;50(6):609 )

Management

Management overview

● antiplatelet drug therapy recommended as initial management in patients with ischemic stroke or
transient ischemic attack associated with extracranial vertebral atherosclerosis (ACCF/AHA Class I,
Level B)
⚬ options include

– aspirin 81-325 mg/day

– combination of aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily
– clopidogrel 75 mg/day

● management of dysphagia

⚬ impaired swallowing common after stroke (especially brainstem stroke)

⚬ aspiration common after medullary infarction and may be inapparent without testing

⚬ all patients with stroke should have swallowing evaluated before initiating any oral intake to
reduce risk of aspiration and pneumonia (AHA/ASA Class I, Level B; CSBPR Evidence Level B; SIGN
Grade C)
⚬ enteral diet should be started within 7 days of admission after an acute stroke (AHA/ASA Class I,
Level B-R)
⚬ for patients with dysphagia, it is reasonable to initially use nasogastric feeding tubes in early phase
of stroke (starting within rst 7 days) and to place percutaneous gastronomy tubes in patients with
longer anticipated inability to swallow safely (> 2-3 weeks) (AHA/ASA Class IIa, Level C-EO)
⚬ all patients who have dysphagia for > 1 week should be assessed to determine suitability for
rehabilitative swallowing therapy program (SIGN Grade D)
⚬ swallowing therapy reported to improve functional feeding status DynaMed Level 3

● see also Cervical artery dissection for treatment of vertebral artery dissection

Medications

● antiplatelet therapy

⚬ antiplatelet drug therapy recommended as initial management in patients with ischemic stroke or
transient ischemic attack associated with extracranial vertebral atherosclerosis (ACCF/AHA Class I,
Level B)
– choice of 1 of the following based on cost, tolerance, patient's risk factors, and other clinical
characteristics
● aspirin 81-325 mg/day
● combination of aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily
● clopidogrel 75 mg/day
 ⚬ patients with extracranial vertebral artery atherosclerosis who are unable to take aspirin (for
reasons other than active bleeding, such as allergy) can take either clopidogrel 75 mg/day or
ticlopidine 250 mg twice daily (ACCF/AHA Class IIa, Level C)
⚬ Reference - Stroke 2011 Aug;42(8):e464 , correction can be found in Stroke 2011 Aug;42(8):e542,
commentary can be found in Circulation 2012 Mar 27;125(12):e520

● recombinant tissue plasminogen activator (tPA)

⚬ tPA reported to be successful for thrombolysis in case report of 56-year-old man with 2 hours
duration of dizziness, gait incoordination, and dysphagia with computed tomography angiography
demonstrating lling defect in right vertebral artery (Neurology 2005 Apr 12;64(7):1232 )
⚬ sudden cardiorespiratory arrest in 39-year-old male with lateral medullary syndrome (with
infarction extending into inferior cerebellum) who was treated with intra-arterial thrombolysis for
vertebral clot that extended into proximal basilar artery (Neurol India 2009 Mar-Apr;57(2):225
full text )

Other management

Assessment of dysphagia

● impaired swallowing common after stroke (especially brainstem stroke) and can result in

⚬ aspiration leading to pneumonia

⚬ poor nutrition and dehydration

STUDY
● SUMMARY
aspiration common after medullary infarction

COHORT STUDY: Arch Neurol 2000 Apr;57(4):478

Details
⚬ based on video uoroscopic swallowing study in 23 patients with pure medullary infarction
⚬ 10 (44%) had aspiration on swallowing
⚬ aspiration occurred in 9 of 13 (69%) with lesions involving middle medullary level and 1 of 10 (10%)
lesions limited to upper or lower medullary levels
⚬ Reference - Arch Neurol 2000 Apr;57(4):478

● all patients with stroke should have swallowing evaluated before initiating any oral intake to reduce
risk of aspiration and pneumonia (AHA/ASA Class I, Level B; CSBPR Evidence Level B; SIGN Grade C)

● initial swallowing screen includes observations of (SIGN Grade B)

⚬ level of consciousness
⚬ postural control
⚬ if cooperative and able to be supported in upright position

– mobilization of oral secretions

– water swallow test

● standardized clinical bedside assessment by trained professional (such as speech therapist)

⚬ various bedside swallowing evaluations appear to have high sensitivity for swallowing dysfunction
DynaMed Level 2

⚬ Standardized bedside Swallowing Assessment (SSA) may detect dysphagia DynaMed Level 2
 ⚬ Toronto Bedside Swallowing Screening Test (TOR-BSST) may rule out dysphagia in stroke patients
DynaMed Level 2

⚬ Gugging Swallowing Screen (GUSS) predicts or rules out aspiration risk after stroke
DynaMed Level 1

⚬ spoon-thick consistency reduces risk of aspiration (compared to liquid consistency) during bedside
assessment of swallowing DynaMed Level 1

● instrumental assessment (video uoroscopy or beroptic endoscopic evaluation of swallow [FEES])

may be useful if bedside swallowing assessment is equivocal or insu cient to guide selection of food
textures and compensatory techniques

● all stroke patients, even after screening, should continue to be monitored during hospital stay for
swallowing problems

● all patients who have dysphagia for > 1 week should be assessed to determine suitability for
rehabilitative swallowing therapy program (SIGN Grade D)

● program of oropharyngeal swallowing rehabilitation in appropriate patients can include restorative

exercises, compensatory techniques, and diet modi cation (SIGN Grade B)

Treatment of dysphagia

● for patients with dysphagia, it is reasonable to initially use nasogastric feeding tubes in early phase of
stroke (starting within rst 7 days) and to place percutaneous gastronomy tubes in patients with
longer anticipated inability to swallow safely, such as a perioid of > 2-3 weeks (AHA/ASA Class IIa, Level
C-EO)

● enteral diet should be started within 7 days of admission after acute stroke (AHA/ASA Class I, Level B-
R)

● during acute care, screen for dysphagia and adjust management strategies accordingly

⚬ screen for dysphagia before patient begins eating, drinking, or taking oral medications in order to
identify risk for aspiration
⚬ if suspected aspiration, consider endoscopic evaluation to verify the presence or absence of
aspiration and to determine physiologic reasons in order to guide treatment plan
⚬ consider implementing oral hygiene protocols to reduce risk of pneumonia
⚬ for patients with dysphagia, consider initially using nasogastric tubes for feeding during rst 7 days
of stroke and placing percutaneous gastrostomy tubes if anticipated inability to swallow safely for
> 2-3 weeks

● for managing dysphagia, do not consider drug therapy, neuromuscular electrical stimulation,
pharyngeal electrical stimulation, physical stimulation, transcranial direct current stimulation, or
transcranial magnetic stimulation as they are of uncertain bene t

● tube feedings may be needed in patients with severe dysphagia

⚬ nasogastric tube required in 40% in series of 130 patients 2

⚬ gastrostomy placement required in 1 patient in series of 18 patients (Neurology 1998

May;50(5):1418 )

STUDY
● SUMMARY
swallowing therapy reported to improve functional feeding status DynaMed Level 3

CASE SERIES: Acta Neurochir Suppl 2005;93:35

Details
⚬ based on case series
⚬ 27 patients with lateral medullary syndrome had functional swallowing therapy included methods
of restitution, compensation, and adaptation
⚬ functional feeding status improved but 30% remained dependent on tube feeding
⚬ Reference - Acta Neurochir Suppl 2005;93:35

Complications and Prognosis

Complications

● autonomic dysfunction may develop and may result in

⚬ tachycardia 1

⚬ bradycardia (Can J Neurol Sci 2009 May;36(3):390 )

⚬ labile blood pressure 1

⚬ respiratory failure 1

⚬ contralateral hyperhidrosis (Stroke 1996 May;27(5):991 full-text )

⚬ vomiting (Stroke 1994 Jul;25(7):1405 )

● central poststroke pain

⚬ based on cohort of 63 patients with lateral medullary infarct

⚬ central poststroke pain syndrome developed in 25% of patients, all within 6 months
⚬ Reference - Neurology 1997 Jul;49(1):120 , commentary can be found in Neurology 1998
May;50(5):1520

● other complications reported in case series and reports

⚬ central sleep apnea (Acta Med Croatica 2010 Oct;64(4):297 [Croatian])

⚬ syndrome of inappropriate antidiuretic hormone secretion (SIADH) in 44-year-old man (Eur Neurol
2005;53(1):35 )
⚬ visual loss from neurotrophic corneal ulceration in 48-year-old man (J Neuroophthalmol 2004
Dec;24(4):345 )
⚬ loss of ability to sneeze in 49-year-old man and 3 other patients (Neurology 2000 Jan 25;54(2):520
), commentary can be found in Neurology 2000 Aug 22;55(4):604
⚬ pruritus in 56-year-old woman 3 weeks poststroke (Neurology 2009 Feb 17;72(7):676 ),
commentary can be found in Neurology 2009 Nov 10;73(19):1605

Prognosis

STUDY
● SUMMARY
14% rate of serious events reported within first 2 weeks following lateral medullary infarction

COHORT STUDY: Neurology 1991 Feb;41(2 (Pt 1)):244

Details
 ⚬ based on cohort study
⚬ 43 patients (mean age 64 years) were identi ed with lateral medullary infarction from population-
based (200,000 persons) stroke registry between 1982 and 1988
⚬ serious events occurred in 14% (6 patients) within rst 2 weeks of lateral medullary infarction

– extension of stroke occurred in 2 patients (and subsequent death in 1)

– death in 4 patients

● nocturnal apnea in 2 patients

● acute myocardial infarction in 2 patients (1 with multisystem failure)

⚬ other complications during acute phase included

– aspiration pneumonia in 3 patients

– hematemesis in 4 patients

⚬ during follow-up period (median time 33 months)

– new posterior circulation strokes in 2 patients (recurrent vertebrobasilar territory stroke

1.9%/year)
– vertebrobasilar transient ischemic attack in 5 patients
– carotid territory strokes in 3 patients

⚬ Reference - Neurology 1991 Feb;41(2 (Pt 1)):244

STUDY
● SUMMARY
most patients with lateral medullary stroke can be discharged from rehabilitation
hospitalization to home with recovery of independent ambulation

COHORT STUDY: Neurology 1998 May;50(5):1418

Details
⚬ based on cohort study
⚬ 18 patients (mean age 60 years) with lateral medullary syndrome admitted to rehabilitation
hospital from 1993 to 1996 were evaluated
⚬ extension of lateral medullary infarction demonstrated in 8 patients

– involvement of cerebellum in 6
– extension of infarction to pontomedullary junction in 2

⚬ all 18 patients were discharged to home

– mean length of stay of acute hospitalization was 13 days

– mean length of stay of rehabilitation hospitalization was 26 days

⚬ dysequilibrium present in

– 100% of patients at admission

– 83% of patients at discharge from rehabilitation hospital

⚬ 13 patients were followed up at mean 12.4 months (4 lost to follow-up and 1 died of cancer)

– 85% were totally independent for ambulation

– 54% had dysequilibrium but reported to be mild without e ect on functional performance
– 5 of 7 previously working patients returned to work
– 8% (1 patient) required ambulatory supervision
– 8% (1 patient) required hands-on contact, but no supervision

⚬ Reference - Neurology 1998 May;50(5):1418

STUDY
● SUMMARY
prognosis may be related to level of lateral medullary lesion

COHORT STUDY: J Stroke Cerebrovasc Dis 2012 Oct;21(7):594

Details
⚬ based on cohort study
⚬ 29 patients with lateral medullary infarcts had magnetic resonance imaging (MRI) on day of
infarction
⚬ strokes were categorized as upper, central, or lower medulla oblongata
⚬ dysphagia more common in upper medullary lesions

– 78% of upper medullary lesions

– 50% of central medullary lesions

⚬ frequency of good recovery at 90 days

– upper medullary group was 22% (2 of 9 patients)

– central medullary group was 52% (10 of 19 patients)
– lower group 100% (1 patient)

⚬ Reference - J Stroke Cerebrovasc Dis 2012 Oct;21(7):594 , 3

● poor outcome after lateral medullary infarctions in 2 patients with severe stenosis of contralateral
vertebral artery (Neurology 1986 Nov;36(11):1510 )

Prevention and Screening

Prevention

● patients with atherosclerosis involving vertebral arteries should get antiplatelet therapy with aspirin
75-325 mg/day to prevent myocardial infarction and other ischemic events if no contraindications
(ACCF/AHA Class I, Level B) (Stroke 2011 Aug;42(8):e464 ), correction can be found in Stroke 2011
Aug;42(8):e542, commentary can be found in Circulation 2012 Mar 27;125(12):e520

● medical therapy and lifestyle modi cation to reduce atherosclerotic risk recommended in patients
with vertebral atherosclerosis (ACCF/AHA Class I, Level B) (Stroke 2011 Aug;42(8):e464 ), correction
can be found in Stroke 2011 Aug;42(8):e542, commentary can be found in Circulation 2012 Mar
27;125(12):e520

Guidelines and Resources

Guidelines

United States guidelines

● American Heart Association/American Stroke Association (AHA/ASA) guideline on early management

of adults with ischemic stroke can be found in Stroke 2018 Mar;49(3):e46 , corrections can be found
in Stroke 2018 Mar;49(3):e138 and Stroke 2018 Jun;49(6):e233

● American College of Cardiology Foundation/American Heart Association (ACCF/AHA) practice guideline

on management of patients with extracranial carotid and vertebral artery disease can be found in
Circulation 2011 Jul 26;124(4):e54 , corrections can be found in Circulation 2011 Jul 26;124(4):e146,
Circulation 2012 Jul 10;126(2):e26
United Kingdom guidelines

● Scottish Intercollegiate Guidelines Network (SIGN) national clinical guideline on identi cation and
management of dysphagia in patients with stroke can be found at SIGN 2010 Jun PDF

Canadian guidelines

● Canadian Stroke Best Practice Recommendations (CSBPR) on

⚬ stroke recognition and response can be found at CSBPR 2018 Jun

⚬ secondary prevention of stroke can be found at CSBPR 2017 Oct
⚬ hyperacute stroke care can be found at CSBPR 2018 Jun
⚬ acute inpatient stroke care can be found at CSBPR 2015 Oct or in Int J Stroke 2016 Feb;11(2):239

⚬ stroke rehabilitation can be found at CSBPR 2015 or in Int J Stroke 2016 Jun;11(4):459
⚬ transitions of care can be found at CSBPR 2016 Jul
⚬ mood, cognition, and fatigue can be found at CSBPR 2019
⚬ Telestroke can be found at CSBPR 2017 Apr or in Int J Stroke 2017 Oct;12(8):886

● Registered Nurses Association of Ontario (RNAO) guideline on stroke assessment across continuum of
care can be found at RNAO 2005 Jun PDF , supplement can be found at RNAO 2011 Aug PDF

Review articles

● review can be found in J Emerg Med 2009 Feb;36(2):176

● review can be found in J Neurol Neurosurg Psychiatry 2000 May;68(5):570 full-text

● review of outcomes of posterior circulation strokes can be found in Arch Neurol 2002 Mar;59(3):369
full-text , editorial can be found in Arch Neurol 2002 Mar;59(3):359

● review of crossed brainstem syndromes (including lateral medullary syndrome) can be found in J
Neurol 2009 Jun;256(6):898

● review of vertebrobasilar disease can be found in N Engl J Med 2005 Jun 23;352(25):2618

● case presentation of inappropriate secretion antidiuretic hormone associated with lateral medullary
syndrome can be found in BMC Neurol 2016 Jul 27;16:119 full-text , correction can be found in
BMC Neurol 2016 Oct 3;16(1):192

MEDLINE search

● to search MEDLINE for (Wallenberg stroke OR lateral medullary syndrome) with targeted search
(Clinical Queries), click therapy , diagnosis , or prognosis

Patient Information

● handout from National Institute of Neurological Disorders and Stroke

ICD Codes
ICD-10 codes

● G46.3 brainstem stroke syndrome

● I63 cerebral infarction

⚬ I63.3 cerebral infarction due to thrombosis of cerebral arteries

⚬ I63.4 cerebral infarction due to embolism of cerebral arteries
⚬ I63.5 cerebral infarction due to unspeci ed occlusion or stenosis of cerebral arteries

● I65 occlusion and stenosis of vertebral artery, not resulting in cerebral infarction

● I66.8 occlusion and stenosis of other cerebral artery

● I69.4 sequelae of cerebral infarction

References

General references used

1. Gan R, Noronha A. The medullary vascular syndromes revisited. J Neurol. 1995 Mar;242(4):195-202

2. Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive
patients. Brain. 2003 Aug;126(Pt 8):1864-72 full-text

3. Fukuoka T, Takeda H, Dembo T, et al. Clinical review of 37 patients with medullary infarction. J Stroke
Cerebrovasc Dis 2012 Oct;21(7):594

Recommendation grading systems used

● Scottish Intercollegiate Guidelines Network (SIGN) de nitions of grades of recommendation and levels
of evidence
⚬ grades of recommendation

– Grade A

● at least 1 meta-analysis, systematic review, or randomized controlled trial (RCT) that is rated
as 1++, and directly applicable to the target population, or
● a body of evidence consisting principally of studies rated as 1+, directly applicable to the
target population and demonstrating overall consistency of results
– Grade B

● a body of evidence that includes studies rated as 2++, directly applicable to the target
population and demonstrating overall consistency of results, or
● extrapolated evidence from studies rated as 1++ or 1+

– Grade C

● a body of evidence that includes studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results, or
● extrapolated evidence from studies rated as 2++

– Grade D

● evidence level 3 or 4, or
● extrapolated evidence from studies rated as 2+
 – Good Practice Point - recommended best practice based on clinical experience of guideline
development group
⚬ levels of evidence

– 1++ - high-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
– 1+ - well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
– 1- - meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
– 2++

● high-quality systematic reviews of case-control or cohort studies

● high-quality case-control or cohort studies with a very low risk of confounding or bias and a
high probability that the relationship is causal
– 2+ - well-conducted case-control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
– 2- - case-control or cohort studies with a high risk of confounding or bias and a signi cant risk
that the relationship is not causal
– 3 - nonanalytical studies (for example, case reports, case series)
– 4 - expert opinion

⚬ Reference - SIGN national clinical guideline on management of patients with stroke: identi cation
and management of dysphagia (SIGN 2010 Jun PDF )

● Canadian Stroke Best Practice Recommendations (CSBPR) levels of evidence

⚬ Evidence Level A

– meta-analysis of randomized controlled trials or consistent ndings from ≥ 2 randomized trials

– desirable e ects clearly outweigh undesirable e ects or vice versa

⚬ Evidence Level B

– single randomized controlled trial or consistent ndings from ≥ 2 well-designed nonrandomized

and/or uncontrolled trials, and large observational studies
– desirable e ects outweigh or are closely balanced with undesirable e ects or vice versa

⚬ Evidence Level C

– writing group consensus and/or supported by limited research evidence

– desirable e ects outweigh or are closely balanced with undesirable e ects or vice versa

⚬ Reference - CSBPR Overview and Methodology (CSBPR 2014 PDF )

● American Heart Association/American Stroke Society (AHA/ASA) 2018 grading system for
recommendations
⚬ classi cations of recommendations

– Class I - procedure or treatment should be performed or administered

– Class IIa - reasonable to perform procedure or administer treatment, but additional studies with
focused objectives needed
– Class IIb - procedure or treatment may be considered; additional studies with broad objectives
needed, additional registry data would be useful
– Class III - procedure or treatment should not be performed or administered because it is not
helpful or may be harmful
● Class III ratings may be subclassi ed as Class III No Bene t or Class III Harm

⚬ levels of evidence
 – Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-
quality randomized controlled trials
– Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of
moderate-quality randomized controlled trials
– Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial,
observational studies, or registry studies, or meta-analysis of such studies
– Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-
analyses of such studies
– Level C-EO - consensus of expert opinion based on clinical experience

⚬ Reference - AHA/ASA 2018 guideline on early management of patients with acute ischemic stroke
(Stroke 2018 Mar;49(3):e46 ), correction can be found in Stroke 2018 Mar;49(3):e138

● American Heart Association/American Stroke Association (AHA/ASA) grading system for

recommendations
⚬ classi cations of recommendations

– Class I - procedure or treatment should be performed or administered

– Class IIa - reasonable to perform procedure or administer treatment, but additional studies with
focused objectives needed
– Class IIb - procedure or treatment may be considered; additional studies with broad objectives
needed, additional registry data would be useful
– Class III - procedure or treatment should not be performed or administered because it is not
helpful or may be harmful
● Class III ratings may be subclassi ed as Class III No Bene t or Class III Harm

⚬ levels of evidence

– Level A - data derived from multiple randomized clinical trials or meta-analyses

– Level B - data derived from single randomized trial or nonrandomized studies
– Level C - only expert opinion, case studies, or standard of care

⚬ Reference - AHA/ASA guideline on early management of adults with ischemic stroke (Stroke 2013
Mar;44(3):870-947 full-text )

● American College of Cardiology Foundation/American Heart Association (ACCF/AHA) grading system

for recommendations
⚬ classi cations of recommendations

– Class I - procedure or treatment should be performed or administered

– Class IIa - reasonable to perform procedure or administer treatment, but additional studies with
focused objectives needed
– Class IIb - procedure or treatment may be considered; additional studies with broad objectives
needed, additional registry data would be useful
– Class III - procedure or treatment should not be performed or administered because it is not
helpful or may be harmful
● Class III ratings may be subclassi ed as Class III No Bene t or Class III Harm

⚬ levels of evidence

– Level A - data derived from multiple randomized clinical trials or meta-analyses

– Level B - data derived from single randomized trial or nonrandomized studies
– Level C - only expert opinion, case studies, or standard of care

⚬ Reference - ACCF/AHA practice guideline on management of patients with extracranial carotid and
vertebral artery disease (Stroke 2011 Aug;42(8):e464 full-text ), correction can be found in
 Stroke 2011 Aug;42(8):e542, commentary can be found in Circulation 2012 Mar 27;125(12):e520

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

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