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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 48-50

Wallenberg syndrome with ipsilateral upper motor neuron facial palsy: A rare manifestation


Department of Neurology, GMC, Kota, Rajasthan, India

Date of Submission31-Jul-2020
Date of Decision22-Sep-2020
Date of Acceptance06-Oct-2020
Date of Web Publication06-Jan-2022

Correspondence Address:
Dr. Pallav Jain
Department of Neurology, GMC, Kota - 324 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_57_20

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  Abstract 


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 May 26];10:48-50. Available from: https://www.ajim.in/text.asp?2022/10/1/48/335083




  Introduction Top


In 1885, Wallenberg gave the descriptions of lateral medullary syndrome.[1]

Occlusion of intracranial vertebral artery (67%) or posterior inferior cerebellar artery (10%) most often leads to lateral medullary infarction.[2] Patients with lateral medullary syndrome presents with ipsilateral ataxia, contralateral hyperalgesia, and Horner syndrome.[3] Depending on the involvement of other structures in the brainstem, patients can have corresponding signs and symptoms [Table 1].[4]
Table 1: Clinical features with possible structures involved

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Facial nerve involvement is seen in around 23.5% of the cases.[5] 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.[6],[7]


  Case Report Top


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.
Figure 1: Showing UMN Facial Palsy

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Figure 2: Deviation of Uvula to left side

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Figure 3: Right Dorsolateral Medullary infarct

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  Discussion Top


The facial nucleus is located in the dorsolateral part of the caudal pons.[8]

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.[8] If lateral medullary syndrome extends rostrally, it may cause ipsilateral LMN type of facial palsy as it can involve facial nucleus,[9] 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.[10],[11]

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.[12]

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.[6]
Figure 4: Schematic diagram for the Hypothetical supranuclear fibre loop. [6] 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 Top


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.

Acknowledgment

All authors have approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wallenberg A. Acute bulbar palsy. Posterior inferior cerebellar artery embolism. Arch Psychiatry 1895;27:504-40.  Back to cited text no. 1
    
2.
Kim JS. Pure lateral medullary infarction: Clinical-radiological correlation of 130 acute, consecutive patients. Brain 2003;126:1864-72.  Back to cited text no. 2
    
3.
Sacco RL, Freddo L, Bello JA, Odel JG, Onesti ST, Mohr JP. Wallenberg's lateral medullary syndrome. Clinical-magnetic resonance imaging correlations. Arch Neurol 1993;50:609-14.  Back to cited text no. 3
    
4.
Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. Ch.15., 7th ed. Phildelphia: Brainstem; 2016. p. 420-4.  Back to cited text no. 4
    
5.
Kim JS, Lee JH, Choi CG. Patterns of lateral medullary infarction: Vascular lesion-magnetic resonance imaging correlation of 34 cases. Stroke 1998;29:645-52.  Back to cited text no. 5
    
6.
Srinivasan M, Bindu B, Gobinathan S, Balasubramanian S, Nityanandan A, Shanbhogue KR. An unusual presentation of lateral medullary syndrome with ipsilateral UMN facial palsy An anatomical postulate. Ann Indian Acad Neurol 2005;8:37-40.  Back to cited text no. 6
  [Full text]  
7.
Venugopal K, Kushal DP, Shyamala G, Mohammed MZ, Naik S, Santosh Kumar DP. A stochastic variant of Wallenberg syndrome with ipsilateral central facial palsy. J Mahatma Gandhi Inst Med Sci 2016;21:140-3.  Back to cited text no. 7
  [Full text]  
8.
Patten J, editor. The brain stem. In: Neurological Differential Diagnosis. 2nd ed. London: Springer; 1996. p. 162-77.  Back to cited text no. 8
    
9.
Caplan LR. Caplan's Stroke: A Clinical Approach. 3rd ed. Cambridge University press,UK : Saunders; 2000. p. 207-8.  Back to cited text no. 9
    
10.
Terao S, Takatsu S, Izumi M, Takagi J, Mitsuma T, Takahashi A, et al. Central facial weakness due to medial medullary infarction: The course of facial corticobulbar fibres. J Neurol Neurosurg Psychiatry 1997;63:391-3.  Back to cited text no. 10
    
11.
Urban PP, Wicht S, Vucorevic G, Fitzek S, Marx J, Thömke F, et al. The course of corticofacial projections in the human brainstem. Brain 2001;124:1866-76.  Back to cited text no. 11
    
12.
Currier RD. The medial medullary syndrome. J Univ Mich Med Cent 1976;42:96-104.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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