An Accountant Who Loves Aerobics With Hiccups and Incoordination

Ajith Goonetilleke, MB BS, FRCP


July 02, 2021

The lateral medullary syndrome (also called Wallenberg or posterior inferior cerebellar artery [PICA] syndrome) was first described by Gaspard Vieusseux in 1808. Subsequent clinical (1895) and autopsy (1901) descriptions by Wallenberg led to the syndrome being associated with his name. The loss of pain and temperature sensation on the ipsilateral side of the face and contralateral side of the body is characteristic of this condition. Other clinical features include intractable hiccups, vertigo, Horner syndrome, nystagmus, dysarthria, dysphagia, and ipsilateral ataxia.

The blood supply to the medulla is mainly from the vertebral arteries. At the level of the lower medulla, each vertebral artery gives off a variable branch named the posterior inferior cerebellar artery (which may be absent in up to 25% of the population) that supplies the dorsolateral aspects of the medulla. At a higher level, approaching the pontomedullary junction, each vertebral artery also contributes branches to form the anterior spinal artery, which descends over the anterior surface of the medulla and supplies the medial aspects of the medulla.

Most cases of Wallenberg syndrome are therefore due to vascular events, whereby the dorsolateral aspect of the medulla may be involved, with sparing of the medial medulla due to an intact anterior spinal artery supply. Definitive pathologic[1] and more recent MRI[2] studies indicate that lateral medullary infarctions occur due to involvement of the vertebral artery in 38% of cases. PICA is involved 14%-24% of the time, and both arteries are involved in 26% of cases. No abnormality is found in either vessel only 12%-19% of the time.

Intravenous thrombolysis (IVT) is an acute treatment of the lateral medullary syndrome. Studies show that IVT using recombinant tissue plasminogen activator (tPA) is efficacious for acute ischemic stroke. Dissection is not an absolute contraindication to IVT; however, if a vertebral artery dissection extends intracranially (which is uncommon), caution is advised due to an increased risk for bleeding. The ECASS 3 trial demonstrated benefit of IVT given up to 4.5 hours after symptom onset in ischemic stroke, although certain patients were excluded from this trial and tPA has not received FDA approval for use in this later time frame.[3] Newer, invasive, stent-based techniques exist for stroke and dissection treatment, though they are available at very few centers. If a patient with a nonhemorrhagic stroke is seen beyond the time window for IVT, then aspirin may be given. In this case, vertebral artery dissection was present, anticoagulation with heparin and subsequently warfarin was indicated.

The mechanism of the intractable hiccups that is often observed in the lateral medullary syndrome is poorly understood. Occasionally, gabapentin or chlorpromazine is effective. Patients may experience disturbed vision due to persistent nystagmus, and this may be helped by gabapentin or memantine.[4]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.