What is the management and treatment of Wallenberg syndrome (lateral medullary syndrome)?

Management and Treatment of Wallenberg Syndrome (Lateral Medullary Syndrome)

Brain MRI with diffusion-weighted imaging is the gold standard for diagnosis and treatment of Wallenberg syndrome, followed by a comprehensive rehabilitation program including physical, occupational, and speech therapy to address specific deficits. 1

Diagnosis

• Imaging:

  • Brain MRI with diffusion-weighted imaging is essential, focusing on the posterior fossa and skull base 1
  • Thin-cut high-resolution techniques should be used to visualize the posterior fossa, skull base, and medulla 1
  • Contrast administration is recommended to identify potential underlying causes 1
  • CT has limited utility in brainstem infarctions and should not be used as the primary diagnostic tool 1, 2
  • Initial MRI may be normal; repeat imaging after 2-3 days if clinical suspicion is high 2

• Clinical Assessment:

  • Evaluate for classic signs:
    • Ipsilateral Horner syndrome (ptosis, miosis, anhidrosis)
    • Ipsilateral cerebellar signs (ataxia, dysmetria)
    • Ipsilateral facial pain and temperature sensory loss
    • Contralateral body pain and temperature sensory loss
    • Dysphagia and dysphonia
    • Vertigo and nystagmus 3
  • Assess cranial nerves IX-XII for deficits 1

Acute Treatment

1. Standard Ischemic Stroke Management:

   • For patients presenting within the appropriate time window, consider thrombolysis following standard stroke protocols
   • Antiplatelet therapy (aspirin, clopidogrel) for secondary prevention
   • Blood pressure management according to stroke guidelines

2. Symptomatic Management:

   • Vertigo and nausea: Antiemetics (ondansetron, promethazine)
   • Dysphagia: Early swallowing assessment; consider nasogastric tube or gastrostomy tube placement if severe 4
   • Respiratory issues: Consider respiratory assistive devices for patients with respiratory insufficiency 1

3. For Vertebral Artery Dissection:

   • Anticoagulation (heparin followed by warfarin) or antiplatelet therapy depending on the clinical scenario 5
   • Duration of therapy typically 3-6 months

Rehabilitation

• Early initiation of rehabilitation is crucial for improved outcomes
• Physical therapy: Focus on balance training, coordination exercises, and gait training
• Occupational therapy: Address activities of daily living and upper extremity function
• Speech therapy: For dysphagia and dysarthria management 1
• Specialized stroke rehabilitation centers are recommended for optimal outcomes 1

Monitoring and Follow-up

• Regular assessment of neurological status during acute phase
• Swallowing evaluations before initiating oral intake
• Cardiac monitoring for potential arrhythmias (particularly atrial fibrillation) 4
• Follow-up imaging to assess evolution of the infarct

Special Considerations

• Dysphagia management: Critical to prevent aspiration pneumonia
• Ataxia and balance issues: Fall prevention strategies are essential
• Vertigo: May be severe and persistent, requiring specific vestibular rehabilitation
• Pain syndromes: Central post-stroke pain may develop and require specific pain management

Prognosis

Most patients with Wallenberg syndrome have a relatively good prognosis with appropriate management and rehabilitation, though complete recovery may take months. Dysphagia and ataxia are often the most persistent symptoms requiring long-term management.

Pitfalls to Avoid

• Failing to repeat MRI when initial imaging is negative but clinical suspicion is high 2, 6
• Overlooking dysphagia, which can lead to aspiration pneumonia
• Neglecting to assess for vertebral artery dissection as a potential cause
• Delaying initiation of rehabilitation services
• Missing atrial fibrillation as a potential cause or complication 4