lateral_medullary_syndrome

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lateral_medullary_syndrome [2025/05/15 11:10] – [Case reports] administradorlateral_medullary_syndrome [2025/05/15 11:11] (current) – administrador
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 ===== Case reports ===== ===== Case reports =====
-====== Thunderclap Headache as a Rare Heralding Symptom of Wallenberg Syndrome: A Diagnostic Challenge ====== 
  
 **Abstract**   **Abstract**  
 A 65-year-old woman presented with sudden, severe frontal headache and nausea, initially without neurological deficits. MRI scans at presentation and 8 hours later were normal. However, progression to vertigo, right facial sensory disturbance, and dysphagia led to further imaging, which revealed a lateral medullary infarction—confirming **Wallenberg syndrome**. This rare case highlights thunderclap headache as an unusual initial manifestation of posterior circulation stroke. A 65-year-old woman presented with sudden, severe frontal headache and nausea, initially without neurological deficits. MRI scans at presentation and 8 hours later were normal. However, progression to vertigo, right facial sensory disturbance, and dysphagia led to further imaging, which revealed a lateral medullary infarction—confirming **Wallenberg syndrome**. This rare case highlights thunderclap headache as an unusual initial manifestation of posterior circulation stroke.
  
----- +1. Clinical Presentation and Diagnostic Surprise 
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-===== 1. Clinical Presentation and Diagnostic Surprise =====+
  
 The patient's presentation deviated from the classical signs of lateral medullary syndrome. Rather than vertigo or ataxia, she experienced a **thunderclap headache**, prompting initial concern for subarachnoid hemorrhage (SAH). However, no SAH was found, and neurological symptoms evolved over hours. The patient's presentation deviated from the classical signs of lateral medullary syndrome. Rather than vertigo or ataxia, she experienced a **thunderclap headache**, prompting initial concern for subarachnoid hemorrhage (SAH). However, no SAH was found, and neurological symptoms evolved over hours.
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 This delayed evolution underscores that **thunderclap headache can, in rare instances, precede medullary infarction**—a fact not widely appreciated in clinical practice. This delayed evolution underscores that **thunderclap headache can, in rare instances, precede medullary infarction**—a fact not widely appreciated in clinical practice.
  
----- +2. Imaging Challenges in Posterior Circulation Stroke 
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-===== 2. Imaging Challenges in Posterior Circulation Stroke =====+
  
 Despite two MRIs performed within the first 8 hours, **no abnormalities were detected initially**. This aligns with known limitations of diffusion-weighted imaging (DWI) in the posterior fossa, where small infarcts may evade early detection due to technical factors. Despite two MRIs performed within the first 8 hours, **no abnormalities were detected initially**. This aligns with known limitations of diffusion-weighted imaging (DWI) in the posterior fossa, where small infarcts may evade early detection due to technical factors.
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 > **Comment:** Repeat MRI was appropriately performed based on symptom progression. However, inclusion of high-resolution vessel wall imaging could have excluded subtle vertebral artery dissection with greater confidence. > **Comment:** Repeat MRI was appropriately performed based on symptom progression. However, inclusion of high-resolution vessel wall imaging could have excluded subtle vertebral artery dissection with greater confidence.
  
----- +3. Diagnostic Pitfalls and Missed Opportunities 
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-===== 3. Diagnostic Pitfalls and Missed Opportunities =====+
  
 This case reinforces a crucial teaching point: **progressive neurological signs should override early negative imaging**, especially in posterior fossa stroke. This case reinforces a crucial teaching point: **progressive neurological signs should override early negative imaging**, especially in posterior fossa stroke.
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 > **Comment:** A lumbar puncture could have been considered initially to rule out SAH, given the thunderclap onset. However, the development of focal signs reoriented suspicion toward ischemic stroke. > **Comment:** A lumbar puncture could have been considered initially to rule out SAH, given the thunderclap onset. However, the development of focal signs reoriented suspicion toward ischemic stroke.
  
----- +4. Treatment and Hospital Course 
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-===== 4. Treatment and Hospital Course =====+
  
 The patient received **dual antiplatelet therapy (DAPT)**—appropriate for minor non-cardioembolic stroke per **CHANCE** and **POINT trials**. Persistent **dysphagia** required prolonged admission and transfer to a rehabilitation center by hospital day 27. The patient received **dual antiplatelet therapy (DAPT)**—appropriate for minor non-cardioembolic stroke per **CHANCE** and **POINT trials**. Persistent **dysphagia** required prolonged admission and transfer to a rehabilitation center by hospital day 27.
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 > **Comment:** Early speech therapy and consideration of PEG feeding should be standard in brainstem strokes with severe dysphagia. > **Comment:** Early speech therapy and consideration of PEG feeding should be standard in brainstem strokes with severe dysphagia.
  
----- +5. Clinical Takeaways 
- +
-===== 5. Clinical Takeaways =====+
  
   * **Thunderclap headache** may rarely signal posterior circulation infarction—not only SAH.   * **Thunderclap headache** may rarely signal posterior circulation infarction—not only SAH.
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   * **Clinical vigilance must override early negative radiology**.   * **Clinical vigilance must override early negative radiology**.
  
----- +Conclusion 
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-===== Conclusion ===== +
- +
-This case expands the known presentations of **Wallenberg syndrome**, urging caution against premature exclusion of ischemic stroke in the face of negative early imaging. It is a powerful reminder that **progressive symptoms demand ongoing reassessment**, and that **stroke syndromes may start subtly, or unusually**. +
  
 +This case expands the known presentations of **Wallenberg syndrome**, urging caution against premature exclusion of ischemic stroke in the face of negative early imaging. It is a powerful reminder that **progressive symptoms demand ongoing reassessment**, and that **stroke syndromes may start subtly, or unusually**
 ((Nozaki Y, Yamamoto M, Demura K, Sakakibara Y. A Case of Wallenberg Syndrome Presenting With Thunderclap Headache and Delayed Diagnosis Due to Negative Findings on Two MRI Examinations. Cureus. 2025 Apr 14;17(4):e82236. doi: 10.7759/cureus.82236. PMID: 40370879; PMCID: PMC12077382.)) ((Nozaki Y, Yamamoto M, Demura K, Sakakibara Y. A Case of Wallenberg Syndrome Presenting With Thunderclap Headache and Delayed Diagnosis Due to Negative Findings on Two MRI Examinations. Cureus. 2025 Apr 14;17(4):e82236. doi: 10.7759/cureus.82236. PMID: 40370879; PMCID: PMC12077382.))
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