CASE PRESENTATION
A 42-year-old woman, nonalcoholic and nonsmoking, with no history of
prior surgical or medical conditions, arrived at the emergency
department reporting vomiting, body swaying while walking, speech
difficulties, swallowing issues, and facial numbness that persisted for
one month. The vomiting episodes were projectile, occurring ten to
fifteen times daily, with food particles but no blood. There was no
reported history of trauma, falls, headaches, weakness, double vision,
abdominal pain, water rash, yellow discoloration of the body or sclera,
fever, shortness of breath, fever, loss of consciousness, or episodes of
seizures.
Upon arrival at the hospital, the patient appeared pale and unwell, with
a pulse of 86 beats/min, regular rhythm, and a blood pressure of 110/60
mm Hg. Her respiratory rate was 22 breaths/min, with oxygen saturation
(SpO2) at 96%, and her temperature was 97.2°F. She demonstrated a
Glasgow Coma Scale (GCS) score of 15/15 (E4M5V6). Neurological
examination revealed scanning speech, nystagmus, exaggerated jaw jerk
with deviation to the right (CN V), decreased gag reflex on the right
(CN IX, X), reduced tongue power, and inability to protrude the tongue
(CN XII), bilateral upper and lower limb power rated at 4/5 except for
bilateral knee flexion and extension, which were 5/5. There was
decreased pain and temperature sensation in the right upper extremities,
impaired bilateral lower extremity joint proprioception, right-sided
dysdiadochokinesia, truncal ataxia, and wide-based gait. Cardiac
auscultation revealed normal heart sounds without murmurs, and there was
no evidence of limb edema on examination. Other systemic examinations
did not produce abnormal findings.
All blood tests returned within normal ranges. MRI brain imaging
revealed low signal intensity T1(Figure 1) and high signal intensity T2
/ FLAIR(Figure 2)in the right lateral aspect of the pons, midbrain, and
right middle cerebellar peduncle. This region exhibited restricted
diffusion on DWI(Figure 3), with pseudonormalization evident in ADC map
images(Figure 4). Additionally, patchy enhancement areas were observed
in the peripheral aspect of the lesion. Based on a comprehensive
clinical evaluation, physical examinations, laboratory results, and
imaging findings, a diagnosis of lateral medullary syndrome was
established. Further evaluation of speech and swallowing functions was
conducted. The patient underwent conservative management with
enoxaparin, aspirin, and atorvastatin. In conjunction with
pharmacotherapy, she received speech therapy, swallowing therapy, and
physical therapy, resulting in significant improvement. The patient did
not experience complications and was discharged after 7 days with
instructions for physical rehabilitation. At 90 days of follow-up, she
exhibited a favorable functional outcome.