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Wallenberg Syndrome 1

Topic: Behavior

Created on Sunday, September 17 2006 by jdmiles

Last modified on Sunday, November 16 2008.

A famous elderly, retired model presents to the E.R. She had no neurologic defecits prior to this morning, when she awoke to several new symptoms, the most concerning to her of which are changes in the way her face looks, as shown in the image above.
She has smoked 4 packs of cigarettes per day for the past 64 years. She is overweight, has sleep apnea, and a recent LDL cholesterol level was 613 mg/dL. She has diabetes mellitus, and a recent hemoglobin A1C was 16. She has a history of poorly controlled hypertension. She is noncompliant with the medications prescribed to her for these conditions.
History and physical exam reveal new onset of decreased motion of the vocal cord on the right, lateropulsion to the right, nystagmus, an illusion of titling of vision, diminished gag reflex, hoarseness, anhidrosis in the right face, decreased elevation of the palate on the right, nausea and vomiting, vertical diplopia, vertigo, paresthesias on the right side of the face, oscillopsia, and ataxia on the right.
Of the following choices, which ONE other finding would you MOST expect to see in this patient?

A) Loss of gustation

B) Agraphia

C) Loss of olfaction

D) Festination

E) Cerebral atrophy

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This question was created on September 17, 2006 by jdmiles.
This question was last modified on November 16, 2008.

ANSWERS AND EXPLANATIONS

A) loss of gustation

This answer is correct.

This patient presents with history and physical findings consistent with a stroke in the lateral medulla (Wallenberg syndrome). Her findings are consistent with infarction on the right side of the medulla. A stroke in this location will cause damage to the vestibular nuclei, spinothalamic tract, descending sympathetic fibers, descending fibers of cranial nerves IX and X, and cerebellar tracts including the inferior cerebellar peduncle.
Damage to these structures produces a predictable constellation of symptoms, including nystagmus, vertigo, oscillopsia, nausea and vomiting, loss of pain and temperature in the contralateral half of the body, loss of pain and temperature sensation in the ipsilateral face, an ipsilateral Horner's syndrome (as shown in the image), hoarseness and dysphagia, ataxia, and ipsilateral lateropulsion.
You could expect to see loss of gustation in this patient. (See References)


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B) agraphia

This answer is incorrect.

Agraphia is not a component of the lateral medullary (Wallenberg) syndrome, and would not be expected from a lesion of the lateral medulla. (See References)


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C) loss of olfaction

This answer is incorrect.

Loss of olfaction would be seen in a left lateral medullary infarct, but not in a right lateral medullary infarct, which this patient has. (See References)


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D) festination

This answer is incorrect.

Festination is not a component of the lateral medullary (Wallenberg) syndrome, and would not be expected from a lesion of the lateral medulla. (See References)


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E) cerebral atrophy

This answer is incorrect.

Cerebral atrophy is not a component of the lateral medullary (Wallenberg) syndrome, and would not be expected from a lesion of the lateral medulla. (See References)


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References:

1. Zaidat, O.O., and Lerner, A.J. (2002). The Little Black Book of Neurology, 4th Edition. Mosby, St. Louis. (ISBN:0323014151)	Advertising:
2. Victor, M., and Ropper, A.H. (2001). Adams and Victor's Principles of Neurology, 7th Edition. McGraw-Hill, New York. (ISBN:0070674973)	Advertising:


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behavior
Wallenberg Syndrome 1
Question ID: 69171
Question written by J. Douglas Miles, (C) 2006-2009, all rights reserved.
Created: 09/17/2006
Modified: 11/16/2008
Estimated Permutations: 0

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jdmiles

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