WALLENBERG ' S SYNDROME IN YOUNG ADULTS : CASE REPORT Affiliation

Wallenberg's syndrome which is also known as Lateral medullary syndrome and posterior inferior cerebellar artery syndrome is a very rare cause of cerebrovascular accident (CVA). This has variability of presenta on which cause the under diagnose for Wallenberg Syndrome. Generally ischemic CVA and especially medullary infarc on occurs in the old pa ents but here we report two cases of Wallenberg syndrome in young adults, first is 35 years male and second is 38 years female.


INTRODUCTION
The Wallenberg Syndrome or lateral medullary syndrome is caused mainly by infarc on of lateral medulla in which most associa on found was with vertebral artery(VA), followed by posterior inferior cerebellar artery (PICA), superior, middle and inferior medullary arteries.The typical signs and symptoms of LMS are hemisensory disturbance over ipsilateral face and contralateral body is crossed and presence of ipsilateral cerebellar signs and ipsilateral Horner syndrome.The Wallenberg syndrome was first described and showed the onset was sudden on most cases.Among nonsudden onset, first signs and symptoms are usually ver go, headache, gait ataxia or dizziness.Sensory signs like hiccups, hoarseness and dysphagia occur later.Pa ents signs and symptoms are categorized into very common (90%), moderately common (50% to 70%) and less common (<40%).The most common signs and symptoms are sensory 2 symptoms/ signs, dizziness, gait ataxia and Horner sign.The most frequent manifesta ons are Sensory signs and symptoms.

CASE REPORT : 1
35 years gentleman presented to emergency department with severe headache which was acute onset associated with severe dizziness and vomi ng four hours prior.The pa ent's blood pressure, pulse rate, body temperature and respiratory rate and SpO2 were 130/80 mm/Hg, 80 beats/min, 36°C, 18/min, 98% respec vely and there was no previous history of hypertension.In his physical examina on; he has Horner's syndrome with hemiparesis (4/5 level of musclestrength), increased DTR, Babinski reflex posi ve and ataxia were present.His blood counts (CBC), liver func on test (LFT), renal func on test (RFT) were within normal range and viral serology was nega ve.The pa ent was managed symptoma cally and CT head was obtained which came out normal.A er pa ent got bit comfortable MRI brain was done and right lateral medullary infarc on was seen (Figure 1).Pa ent was admi ed in the ward with the diagnosis of Wallenberg's Syndrome being managed conserva vely with symptoma c medica ons and physiotherapy.36-year-woman admi ed to emergency department with sudden onset of headache and ver go for last 4 hours.The pa ent's blood pressure, respiratory rate, heart rate, temperature and SpO₂ were within normal range.She has no significant past medical or surgical history.In her physical examina on; Horner's syndrome, Babinski reflex posi ve, dysmetria, dysdiadochokinesia on the right side, horizontal nystagmus and ataxia were observed.She was admi ed and acute ver go was managed conserva vely.Same day CT head was done and which was normal.She was then hospitalized and symptoma c management was done and physiotherapy was started.Magne c resonance imaging of brain was achieved once she got be er, which revealed hyper intensity in DWI and FLAIR images at right lateral side of the medulla in brain stem, sugges ve of lateral medullary infarc on (Figure 2).

DISCUSSION
The moderate signs and symptoms of the Wallenberg Syndrome are headache, nausea, vomi ng, ver go, dysphagia, nystagmus and limb ataxia.There are sensory signs affec ng face and cranial nerves on the same site of lesion and body and extremi es opposite site of lesion.It is important to diagnose Wallenberg Syndrome or LMS because about 15% to 26% of the cases may associated with

1 published
in 1961.Similar study done by Kim in 2003 2

3 vertebral
artery dissec on.This syndrome is characterized by loss of pain sensa on and temperature sensa on over 4 same side of face and opposite side of body.The dysphagia, dysarthria are caused by involvement of nucleus ambiguous.If spinal trigeminal nucleus is affected, it leads to have ipsilateral loss of corneal reflex andpain on the face.Ataxia in WS is caused by damage to the cerebellum or the inferior cerebellar peduncle.Horner's syndrome is caused by damage to the hypothalamo-spinal fibers disrup ng sympathe c nervous system.The involvement of ves bular nuclei may leads to ver go and nystagmus.Damage of the 4 cranial trigeminal tract causes palatal myoclonus.Lateral medullary syndrome or WS is a rare cause of stroke among 4 youngs.Generally, lesions in WS are related to involvement of mul ple vessel, dissec on, and poor collateral circula on is larger than that of single-vessel disease, atherothrombosis