|Year : 2022 | Volume
| Issue : 1 | Page : 48-50
Wallenberg syndrome with ipsilateral upper motor neuron facial palsy: A rare manifestation
Vijay Sardana, Pallav Jain
Department of Neurology, GMC, Kota, Rajasthan, India
|Date of Submission||31-Jul-2020|
|Date of Decision||22-Sep-2020|
|Date of Acceptance||06-Oct-2020|
|Date of Web Publication||06-Jan-2022|
Dr. Pallav Jain
Department of Neurology, GMC, Kota - 324 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Lateral medullary syndrome presents with features of ipsilateral Horner syndrome, ipsilateral ataxia, and contralateral hyperalgesia. Patients can have ipsilateral lower motor neuron-type of facial palsy if there is rostral extension of the infarct as it involves the facial nucleus. Presence of ipsilateral upper motor neuron facial palsy is rare, which is due to the involvement of the corticofacial fibers which ascend in the dorsal medulla to reach the facial nerve nucleus. Our case supports the presence of this hypothetical neuroanatomical loop of supranuclear corticofacial fibers.
Keywords: Facial palsy, lateral medullary syndrome, Wallenberg syndrome
|How to cite this article:|
Sardana V, Jain P. Wallenberg syndrome with ipsilateral upper motor neuron facial palsy: A rare manifestation. APIK J Int Med 2022;10:48-50
|How to cite this URL:|
Sardana V, Jain P. Wallenberg syndrome with ipsilateral upper motor neuron facial palsy: A rare manifestation. APIK J Int Med [serial online] 2022 [cited 2022 Jun 29];10:48-50. Available from: https://www.ajim.in/text.asp?2022/10/1/48/335083
| Introduction|| |
In 1885, Wallenberg gave the descriptions of lateral medullary syndrome.
Occlusion of intracranial vertebral artery (67%) or posterior inferior cerebellar artery (10%) most often leads to lateral medullary infarction. Patients with lateral medullary syndrome presents with ipsilateral ataxia, contralateral hyperalgesia, and Horner syndrome. Depending on the involvement of other structures in the brainstem, patients can have corresponding signs and symptoms [Table 1].
Facial nerve involvement is seen in around 23.5% of the cases. Ipsilateral upper motor neuron (UMN) facial palsy is one of the unusual manifestations in lateral medullary syndrome. Here, we report a case of ipsilateral UMN facial palsy in lateral medullary syndrome; to the best of our knowledge, only two cases have been reported in India previously.,
| Case Report|| |
A 58-year-old male patient with a past history of hypertension and diabetes presented With the complaints of sudden-onset imbalance while walking with a tendency to fall toward the right side along with dysphagia and drooling of saliva from the mouth. His vitals were stable. On neurological examination, he had decreased sensation of pain and temperature over the right half of the face, deviation of angle of mouth to the left side, and loss of nasolabial fold on the right side [Figure 1], with preserved forehead wrinkles and without Bell's phenomenon. The uvula was deviated to the left, and drooping of the soft palate was present on the right side with absent gag reflex [Figure 2]. Cerebellar signs were positive on the right side. Rest of the examination was normal. After history taking and examination, a clinical diagnosis of right lateral medullary syndrome was made, and magnetic resonance imaging brain was done which showed right-sided dorsolateral medullary infarct in the posterior inferior cerebellar artery territory [Figure 3]. Other laboratory parameters done included hemoglobin – 12.6 g/dl, total leukocyte count – 6700/mm3, fasting blood sugar – 145 mg/dL, sodium – 134 mEq/l, potassium – 4.4 mEq/l, blood urea – 16 mg/dL, creatinine – 0.9 mg/dL, triglyceride – 146 mg/dL, low-density lipoprotein – 132 mg/dL, high-density lipoprotein – 35 mg/dL.
| Discussion|| |
The facial nucleus is located in the dorsolateral part of the caudal pons.
Contralateral facial paresis of UMN type is seen in lesions of rostral pons, whereas ipsilateral facial paresis of lower motor neuron (LMN) type is seen in lesions involving the inferolateral part of the pons. If lateral medullary syndrome extends rostrally, it may cause ipsilateral LMN type of facial palsy as it can involve facial nucleus, but otherwise lateral medullary syndrome causing ipsilateral UMN type of facial palsy is highly unusual.
It has been hypothesized that there are supranuclear corticobulbar fibers which descend down till the contralateral ventromedial medulla, and thereafter decussate at the level of upper medulla and then ascend gradually to reach the facial nucleus. Damage to these fibers may lead to ipsilateral UMN facial palsy in the lateral medullary infarct.,
It has also been hypothesized that facial corticobulbar fibers leave the pyramidal tract at the pontomedullary junction and descend caudally to at least the middle medullary levels before most of them cross the opposite facial nucleus. Interruption of these fibers by infarction at a predecussation level has been postulated to result in a contralateral UMN facial palsy.
In our patient, UMN facial palsy could be due to damage to the ascending limb of this hypothetical loop as our patient had infarct in the dorsolateral medulla [Figure 3] and [Figure 4]. However, presence of ipsilateral UMN facial palsy in lateral medullary infarct is an unusual occurrence as the presence of this hypothetical loop is in itself an unusual phenomenon.
|Figure 4: Schematic diagram for the Hypothetical supranuclear fibre loop.  A-Bilateral innervation of upper face,B- Facial nerve nucleus,C- Infarct in dorsolateral medulla, possibly in our patient,D- Looping supranuclear fibres,E- Corticospinal tracts,F- Cortico bulabar fibres|
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| Conclusions|| |
Very few cases of lateral medullary syndrome with ipsilateral UMN facial palsy have been reported in India. This case report emphasizes the fact that the involvement of facial nerve in lateral medullary syndrome is a possible occurrence and thus one should not exclude the diagnosis of lateral medullary syndrome if UMN facial nerve palsy is present.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
All authors have approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]