Wallenberg’s syndrome

Additional clinical information: Complaints of dysphagia, right facial droop, slurred speech, left lower extremity weakness following “black-out” secondary to alcohol binge. No known trauma.


Findings

The MRA shows hypoplastic right vertebral artery with areas of stenosis proximally. Long segment occlusion of right vertebral artery from mid-cervical spine to origin of the basilar artery. The MRI shows restricted diffusion involving right lateral medulla consistent with acute ischemic infarct.


Diagnosis: Wallenberg’s syndrome

Acute infarct of the posterolateral right medulla likely secondary to occlusion of the lateral medullary segment of the right PICA Also known as lateral medullary syndrome / Wallenberg's syndrome / PICA syndrome


Key points

Vertebral artery dissection secondary to trauma is an important cause
Can occur spontaneously or after minor trauma
Several case reports of Wallenberg's syndrome following chiropractic manipulation
Hypertension and vascular disease can predispose (FMD, Marfan's, Collagen Vasc Dz.)
Typically occurs in young adults (<45yo); males>females
Best diagnostic clue for acute ischemia/infarction is diffusion restriction with correlating ADC map
Restricted diffusion improves accuracy to 95%

"Time is Brain"
Intravenous Recombinant Tissue Plasminogen Activator (rTPA) therapy window within 3Hr
Intra-arterial rTPA window within 6Hr