BNS 1 SGD: CASE INTEGRATION

CASE 2:

OM, a 65-year-old, male, married, a retired government employee, right-handed from Sampaloc
Manila, was rushed to the ER because of sudden onset of ataxia with severe nausea and
vomiting upon waking up this morning.

His vital signs at the ER were as follows: BP 160/90 CR 102 bpm, regular, RR 22/min.

Pertinent findings in the Neurological Examination: Conscious, coherent, oriented

Unsteady gait, sways to his right

(+) ptosis – right eye

Pupils 1 mm RTL, OD 2-3 mm RTL, OS

(+) hoarseness of voice

(+) absent bilateral gag

Tongue deviated to the right on protrusion

(+) sensory deficit on pain and temperature – right face

(+) sensory deficit on pain and temperature – left extremities (-) Babinski

He’s hypertensive, maintained on Amlodipine + Losartan and, diabetic, on Diamicron and

Metformin. He’s smoker (20 pack years) and occasional beer drinker.

1. Where is the probable lesion/abnormality. Lateralize and localize the lesion. ALON,
DARLENE
Drlene: Lateral medullary infraction

Let’s first discuss the blood supply of the medulla. The Basilar artery is formed by the vertebral
artery. Aside from this, a branch of the vertebral artery is the posterior inferior cerebellar artery
(PICA) which supplies the lateral part of the medulla. Medially, VA branches to form the Anterior
spinal artery. Both VA and ASA supplies the medial part of the medulla.

Here is a rostral cross section of the medulla. The lesion is primarily found in the lateral part of
the medulla. Important Lateral structures that may have been affected are the vestibular
nucleus, inferior cerebellar peduncles contains the spinocerebellar tracts spinal, Spinal nucleus
of trigeminal , nucleus ambiguus (9, 10th nerve), Lateral spinothalamic tract/lemniscus.
Important structure in the medial part of the medulla that has been affected in this case is the
hypoglossal nucleus.

Lateral medullary structures

● Vessel involved: PICA

✔️
● Structures affected & Fuunction: (Manifestations will be explain in #2)
a. Inferior Cerebellar Peduncle
■ Ipsilateral ataxia
■ Function: integrates proprioceptive sensory input with motor vestibular

✔️
functions such as balance, and poisture maintenance.
b. Vestibular Nuclei (8th nerve)
 ■ Ipsilateral nystagmus & Vertigo

✔️
■ Function: It is essential in maintaining posture and equilibrium.
c. Trigeminal Nuclei (5th nerve)
■ Ipsilateral loss of sensations on face
■ Function: Carries temperature, deep or crude touch, and pain sensations

✔️
from the ipsilateral portion of the face.
d. Nucleus ambiguus (9th & 10th nerve)
■ Ipsilateral Dysphagia and loss of Gag reflex
■ Function: the root of the pharyngeal plexus which innervates the
ipsilateral muscles of the pharync, larynx, soft palate , and the upper

✔️
esophagus. It is mainly responsible for swallowing and speaking.
e. Lateral Spinothalamic tract
■ Contralateral loss of pain, touch, and temperature

✔️
■ Function: carries contralateral information about pain and temperature.
f. Descending Sympathetic chain
■ Horner’s syndrome
■ Ipsilareal ptosis, myosis, anhidrosis, loss of cilio-spinal reflex
■ Function: supplies parts of the eye such as the dilator muscles of the
pupil, the palpebra which elevates the eyelid, and some sweat glands on
the face

Medial medullary structures

- vessel involved: Vertebral artey/ anterior spinal artery

✔️
- Structure affected & Manifestation
a. Hypoglossal Nucleus (Supplied by ASA)
i. Ipsilateral 12th nerve palsy
ii. Deviation of tongue towards same side of lesion
iii. Ipsilaterally Innervates the genioglossus muscle of the tongue which
primarily helps with the protrusion of the tongue contralaterally. (Because
there is no innervation to one side(R), it will not be able to move
towardspas the contralateral side(L).)

2. Identify the structures involved with the prominent signs and symptoms observed in
the patient. It would be nice if this can be in a table form. JEREMY, LUIS

STRUCTURES ARTERIAL SUPPLY SIGNS AND JUSTIFICATION

AFFECTED INVOLVED SYMPTOMS

Inferior Cerebellar Ataxia/ Unsteady Gait Damage to the

Peduncle (Patient sways to the inferior cerebellar
Right) peduncle results in
ipsilateral cerebellar
 signs, including
ataxia, dysmetria and
dysdiadochokinesia.

Severe Nausea Damage to the

Vestibular Nuclei vestibular system
Vomiting leads to vomiting,
vertigo and
nystagmus

Pupils 1 mm RTL, Damage to the

Descending Posterior Inferior OD 2-3 mm RTL, OS descending
Sympathetic Fibers Cerebellar Artery and sympathetic fibers
Vertebral Artery Ptosis results in ipsilateral
horners syndrome
(ptosis, miosis, and
anhidrosis)

Nucleus Ambiguus Hoarseness of Voice Injury to the nucleus

and roots of ambiguus and roots
cranial nerves IX and Absent Bilateral Gag of cranial nerves 9
X Reflex and 10 results in
laryngeal, pharyngeal
and palatal
hemiparesis, loss of
gag reflex,
dysphagia,
hoarseness of
voice, dysarthria,
difficulty of breathing
and swallowing.

Hypoglossal Root or Vertebral artery and Right Sided Tongue Injury to the
Nucleus Basilar Artery Deviation hypoglossal root or
(Branches of Anterior nucleus results in the
Spinal Artery) deviation of the
tongue to the
ipsilateral side when
protruded and
atrophy of tongue on
ipsilateral side

Spinal Trigeminal Sensory Deficit on Damage to the spinal

Tract and Pain and trigeminal tract
Nucleus causes ipsilateral
 Temperature (Right loss of pain and
Side of the Face) temperature
sensation from the
Posterior Inferior
face
Cerebellar Artery and
Vertebral Artery
Anterolateral System Sensory Deficit on Damage to the
(Lateral Pain and anterolateral system
Spinothalamic Tract) Temperature (Left results in the
Extremities) contralateral loss of
pain and
temperature from
the limbs and the
torso

None None Negative Babinski Negative babinski

Reflex reflex is normal for
adults

3. Identify and discuss the most likely neurologic syndrome in this case. Explain the
patho-mechanism and structures involved? ZAK, DARELLE

As the patient was diagnosed with hypertension and diabetes, and being maintained on
medications, along with being a smoker, these are prevailing factors that predisposes the
patient to develop Wallenberg’s syndrome or lateral medullary syndrome.

Lateral medullary syndrome, or called as Wallenberg’s syndrome, is caused by the

development of atherothrombotic occlusion of the vertebral artery, followed by occlusion
in the posterior inferior cerebellar artery, and least often, in the medullary arteries, which
are the inferior, middle, or superior medullary vessels. In addition, the most common
form of occlusion for these arteries is atherothrombosis. Anatomically speaking, the
infarcted areas or structures involved by Wallenberg's syndrome are supplied by the
posterior inferior cerebellar artery (PICA), including the vertebral artery and the branches
it forms (anterior spinal artery, basilar artery).

ZAK

Since the structures involved for this case was already thoroughly discussed earlier, and
also how each was involved with the prominent signs and symptoms observed by the
patient, the following list will put emphasis on the arteries occluded, and under it is the
structure it supplies and the signs and symptoms observed.

ARTERIES STRUCTURES AFFECTED SIGNS AND SYMPTOMS

 OCCLUDED OBSERVED

Ataxia/ Unsteady Gait

Inferior Cerebellar Peduncle
(Patient sways to the Right)

Severe Nausea
Vestibular Nuclei
Vomiting

Pupils 1 mm RTL, OD 2-3

mm RTL, OS
Descending Sympathetic
Fibers
Ptosis
Posterior Inferior
Cerebellar Artery and
Vertebral Artery Nucleus Ambiguus and Hoarseness of Voice
roots of
cranial nerves IX and X Absent Bilateral Gag Reflex

Sensory Deficit on Pain and

Spinal Trigeminal Tract and Temperature (Right Side of
Nucleus
the Face)

Anterolateral System Sensory Deficit on Pain and

(Lateral Temperature (Left
Spinothalamic Tract) Extremities)

Vertebral Artery and

Basilar Artery Hypoglossal Root or Right Sided Tongue Deviation
(Branches of Anterior Nucleus
Spinal Artery)