What is the management of Wallenberg's syndrome?

Wallenberg Syndrome (Lateral Medullary Syndrome)

Wallenberg syndrome is a posterior circulation stroke requiring immediate anticoagulation or antiplatelet therapy, supportive care for dysphagia and aspiration risk, and intensive rehabilitation for neurological deficits.

Clinical Presentation

Wallenberg syndrome results from infarction of the lateral medulla, typically in the posterior inferior cerebellar artery territory 1. The classic constellation includes:

• Ipsilateral findings: Horner syndrome, facial pain/numbness, ataxia, dysphonia, dysphagia, decreased gag reflex, impaired taste 1
• Contralateral findings: Loss of pain and temperature sensation in trunk and limbs 1
• Additional symptoms: Vertigo, nystagmus, diplopia, dysarthria 1, 2

The most common presenting symptoms are dysphonia and dysphagia, with ataxic gait being the most frequent physical examination finding (present in 96% of cases) 2.

Diagnostic Approach

MRI with diffusion-weighted imaging (DWI) is the gold standard for diagnosis 3. However, a critical pitfall exists: initial MRI may be completely normal in the acute phase 3.

• If clinical suspicion remains high despite negative initial imaging, repeat MRI in 2-3 days to detect the characteristic hyperintensity on T2-weighted FLAIR and DWI sequences in the lateral medulla 3
• The syndrome is frequently associated with vertebral artery dissection (VAD), particularly in younger patients without traditional stroke risk factors 4

Acute Management

Pharmacological Treatment

Initiate anticoagulation or antiplatelet therapy immediately 4. The optimal treatment remains somewhat controversial, but most patients receive:

• Anticoagulants (preferred for vertebral artery dissection) OR
• Antiplatelet drugs 4

Critical Supportive Care

Dysphagia management is paramount to prevent aspiration pneumonia 5:

• Insert nasogastric tube immediately for nutrition in all patients with significant dysphagia 5
• Monitor for acute dyspnea requiring emergency tracheostomy (occurs in severe cases) 5
• Perform videofluoroscopy to assess swallowing function 5
• Do not attempt oral feeding until swallowing reflex is rehabilitated 5

Airway Protection

• Maintain high vigilance for aspiration risk given vocal fold paralysis and pharyngeal weakness 5
• Emergency tracheostomy may be required for acute respiratory compromise 5

Rehabilitation Protocol

Begin immediate intensive rehabilitation therapy - this is critical for optimal recovery 5:

• Logopedic therapy for dysphonia and dysphagia 5
• Physiokinesitherapy for postural disorders and ataxia 5
• Computerized static posturography shows improvement typically begins after 2 months of therapy 5
• Oral alimentation can only resume after swallowing reflex rehabilitation - timing varies significantly between patients (weeks to months) 5

Prognosis

Most cases have good prognosis with appropriate management 4, 2:

• The most common residual deficit is ataxia 2
• Recovery timeline varies considerably between patients 5
• Early detection and aggressive rehabilitation are critical for optimizing post-stroke recovery 3

Special Considerations

• Young patients without traditional stroke risk factors: Maintain extremely high suspicion for vertebral artery dissection 4
• Progressive onset: Most cases present with gradual symptom development rather than sudden onset 2
• Risk factors: Arterial hypertension is the most common (52% of cases) 2
• Age: Typically affects middle-aged patients (mean age 55 years, range 30-78) 2

Common Pitfalls to Avoid

• Do not dismiss the diagnosis based on negative initial MRI - repeat imaging if clinical suspicion persists 3
• Do not delay nasogastric tube placement - aspiration risk is immediate and severe 5
• Do not underestimate rehabilitation needs - family involvement and immediate therapy initiation are essential 5