The Acute Vestibular Syndrome with Dysarthria, Dysphagia, Dysphonia, Hemi-ataxia, and Saccadic Dysmetria Due to the Lateral Medullary (Wallenberg) Syndrome

𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 50-year-old woman with the acute onset of vertigo, dysarthria, dysphagia and dysphonia/hoarseness (nucleus ambiguus), ptosis and imbalance. Her examination localized to a left lateral medullary (Wallenberg) syndrome - there was decreased sensation on the left side of the face (spinal trigeminal nucleus and tract) and the right arm and leg (spinothalamic tract), a left Horner's syndrome (oculosympathetic tract), left hemi-ataxia (inferior cerebellar peduncle), leftward ocular lateropulsion (apparent throughout the video during blinks - during eyelid closure, there is conjugate deviation to the left, and when the eyelids open, the eyes move to the right into primary gaze) which is usually seen with hypermetric saccades to the left (ipsilateral) and hypometric saccades to the right (contralateral), relating to injury of the climbing fibers traveling through the inferior cerebellar peduncle on the left side. Other ocular motor features commonly seen in a lateral medullary syndrome (not demonstrated in the video) include an ipsiversive ocular tilt reaction (1. skew deviation with a (left) hypotropia ipsilateral to the stroke, 2. ipsilesional (towards the left ear) ocular counterroll, 3. leftward head tilt) due to utricle-ocular motor pathway dysfunction; spontaneous nystagmus which is usually horizontal-torsional or pure torsional due to central semicircular canal pathway dysfunction; gaze-evoked nystagmus due to medial vestibular nucleus dysfunction. [[Number of Videos and legend for each: 1, patient with the acute vestibular syndrome due to left lateral medullary stroke.]] 𝗡𝗲𝘂𝗿𝗼-𝗼𝗽𝗵𝘁𝗵𝗮𝗹𝗺𝗼𝗹𝗼𝗴𝘆 𝗮𝗻𝗱 𝗡𝗲𝘂𝗿𝗼-𝗼𝘁𝗼𝗹𝗼𝗴𝘆 𝗧𝗲𝘅𝘁𝗯𝗼𝗼𝗸 𝗟𝗲𝗴𝗲𝗻𝗱: This patient experienced the acute onset of vertigo, dysarthria, dysphagia and dysphonia/hoarseness (nucleus ambiguus), ptosis and imbalance. Her examination localized to a left lateral medullary (Wallenberg) syndrome - there was decreased sensation on the left side of the face (spinal trigeminal nucleus and tract) and the right arm and leg (spinothalamic tract), a left Horner's syndrome (oculosympathetic tract), left hemiataxia (inferior cerebellar peduncle), leftward ocular lateropulsion (apparent throughout the video during blinks - during eyelid closure, there is conjugate deviation to the left, and when the eyelids open, the eyes move to the right into primary gaze) which is usually seen with ipsilesional (left) hypermetric saccades and contralesional (right) hypometric saccades, due to injury of the climbing fibers traveling through the inferior cerebellar peduncle on the left side. An ipsiversive (leftward) ocular tilt reaction is also commonly seen due to involvement of the utriculo-ocular motor pathway (e.g., left hypotropia from skew deviation, left head tilt, leftward ocular counterroll). (Video courtesy of Dr. Stephen Reich) https:// collections.lib.utah.edu/ark:/87278/s6963fhm