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Vertigo and hoarseness after neck manipulation
A 52-year-old has severe vertigo, nausea, hoarseness and difficulty swallowing that began after a chiropractic neck manipulation. She also has left-sided neck pain.
Step 1 of 4
Pain and temperature sensation are lost on the left face and the right body. She has a left ptosis and a small left pupil, and left limb ataxia. Limb strength is normal.
Where is the lesion?
Correct answer: E
Ipsilateral face and contralateral body pain/temperature loss, dysphagia and hoarseness, ipsilateral Horner syndrome and limb ataxia with no limb weakness is the lateral medullary (Wallenberg) syndrome on the side of the face findings (see medulla oblongata).
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E
Ipsilateral face and contralateral body pain/temperature loss, dysphagia and hoarseness, ipsilateral Horner syndrome and limb ataxia with no limb weakness is the lateral medullary (Wallenberg) syndrome on the side of the face findings (see medulla oblongata).
Step 2 of 4
Which artery is most likely occluded?
Correct answer: B
Wallenberg syndrome comes from the vertebral artery or PICA. Neck pain after manipulation in a younger patient suggests vertebral artery dissection (see vertebrobasilar system). AICA causes a lateral pontine syndrome with hearing loss; the anterior spinal artery causes the medial medullary syndrome.
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B
Wallenberg syndrome comes from the vertebral artery or PICA. Neck pain after manipulation in a younger patient suggests vertebral artery dissection (see vertebrobasilar system). AICA causes a lateral pontine syndrome with hearing loss; the anterior spinal artery causes the medial medullary syndrome.
Step 3 of 4
Damage to which nucleus explains the hoarseness and dysphagia?
Correct answer: B
The nucleus ambiguus supplies the muscles of the pharynx and larynx through CN IX and X. The spinal trigeminal nucleus explains the facial sensory loss and the vestibular nuclei the vertigo.
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B
The nucleus ambiguus supplies the muscles of the pharynx and larynx through CN IX and X. The spinal trigeminal nucleus explains the facial sensory loss and the vestibular nuclei the vertigo.
Step 4 of 4
Which imaging test is best for confirming this stroke?
Correct answer: B
Posterior circulation strokes are easily missed on CT; MRI is the test. Vessel imaging (CTA or MRA) looks for the dissection.
Show answer
B
Posterior circulation strokes are easily missed on CT; MRI is the test. Vessel imaging (CTA or MRA) looks for the dissection.
Key points
- Ipsilateral face + contralateral body pain/temperature loss + hoarseness + Horner → Wallenberg (vertebral/PICA).
- Neck pain + posterior circulation stroke in a younger patient → vertebral dissection.
Study: Medulla oblongata, Vertebrobasilar system, Vertebral artery, Vagus nerve (CN X)