Isolated dysphagia due to a medullary infarction: a new lacunar syndrome

The Trouble with Swallowing: Dysphagia as the Presenting Symptom in Lateral Medullary Syndrome

BACKGROUND

Posterior circulation strokes account for approximately one-fourth of all ischemic strokes, but are frequently misdiagnosed by emergency providers. Current standard stroke screening tools such as the National Institutes of Health Stroke Scale and the Cincinnati Prehospital Stroke Scale are weighted toward anterior circulation stroke diagnosis. Lateral medullary syndrome, a type of posterior circulation stroke, can be particularly challenging to diagnose due to nonspecific presenting symptoms, such as dysphagia.

CASE REPORT

This report describes a 65-year-old man who presented with dysphagia, dizziness, and hoarseness. An initial neurological examination did not reveal any gross deficits, and imaging to evaluate for posterior circulation stroke was not obtained. The patient presented the following day with worsening symptoms, prompting imaging that revealed a large cerebellar ischemic infarction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although dysphagia frequently occurs in lateral medullary syndrome, it is rarely the presenting symptom in the emergency department. In patients with cerebrovascular risk factors who present with dysphagia, a complete neurological examination should be performed and noncontrast computed tomography (CT) of the head should be obtained if a neurological deficit is appreciated. Due to their poor sensitivity, CT scans can frequently miss posterior circulation strokes, therefore magnetic resonance imaging should be considered if provider suspicion remains high. Emergency providers are encouraged to have a high level of suspicion for this rare but debilitating stroke syndrome to avoid misdiagnosis and delayed care.

Atypical presentations of acute cerebrovascular syndromes

Correct diagnosis of acute stroke is of paramount importance to clinicians to enable selection of correct treatments and to ensure prevention of acute complications, including recurrent stroke. Timely diagnosis can be difficult in some cases because patients with acute stroke can present with atypical or uncommon symptoms that suggest another cause altogether. Publications on these patients suggest that the following strategies could help to reduce misdiagnosis. First, clinicians should suspect stroke in any patient with abrupt onset of neurological symptoms. Second, clinicians should be aware that some patients will initially present with various uncommon and atypical stroke symptoms. Third, a complete and systematic neurological examination should be routinely done in patients presenting with acute neurological symptoms because this might shed light on the true nature of the problem. Finally, clinicians should be aware that even with the most sophisticated neuroimaging tests, stroke might be missed in the early hours after the event.

Relationship between speech and swallowing disorders in patients with neuromuscular disease

The intelligibility of monosyllabic speech, word speech, and conversational speech was evaluated in 113 dysarthric speakers, and the presence and severity of swallowing disorders were evaluated using videofluoroscopic and bedside examinations. The results revealed a high correlation between swallowing function and all levels of speech intelligibility. Furthermore, the prevalence of concomitant dysphagia in dysarthric patients was quite high regardless of the primary etiology and time elapsed since the onset. However, the relationship between the two functions is more complex than is initially apparent. The prevalence and severity of dysphagia vary markedly according to the type of dysarthria. Patients in the flaccid, spastic, and mixed categories encompass a broad range of severity levels with many individuals being severely impaired, while patients in the ataxic, hypokinetic, and unilateral upper motor neuron categories seldom have severe concomitant swallowing problems. Furthermore, the correlation coefficient between conversational intelligibility and swallowing function varies considerably according to the type of dysarthria. The correlation was not significant in the flaccid, hypokinetic, and UUMN dysarthria groups. Based on these findings, we discuss herein the clinical management of dysarthric patients with dysphagia.

Vertigo and gait ataxia without usual signs of lateral medullary infarction: a clinical variant related to rostral-dorsolateral lesions

Isolated vertigo and ataxia have not been reported as manifestations of lateral medullary infarction. The author describes 3 patients with lateral medullary infarction who presented with almost isolated vertigo and gait ataxia without usual signs/symptoms of lateral medullary infarction such as facial/hemibody sensory changes, dysphagia, hoarseness, hiccup, limb ataxia, and Horner sign. Brain MRI showed small infarcts selectively involving the most dorsolateral portion of the rostral medulla that corresponds to the vestibulocerebellar pathway. These patients illustrate that lateral medullary infarction may present as an isolated vertigo and gait ataxia. Clinicians should be aware of this clinical variant, because these patients may be misdiagnosed as having labyrinthine disorders.