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Acute stroke presenting as syncope: Wallenberg syndrome

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A man in his 50s presented to the emergency department with two episodes of syncope when standing up. They were not preceded by prodromal symptoms, chest pain, dyspnoea or palpitations. On arrival, the patient mentioned vertigo and instability when standing. Previous medical history was relevant for obesity, hypertension and liver transplant 3 years prior due to alcoholic cirrhosis. Physical examination showed multidirectional, nonsuppressible, nystagmus, righteye ptosis and myosis, loss of pain and temperature over the left side of the body (sparing face) and rightsided cerebellar hemiataxia. Romberg sign was absent due to severe unsteadiness when standing. Vital signs were normal and there was no difference between rightarm and leftarm pulse or blood pressure. Orthostatic vitals were not recorded. Blood glucose on admission was normal, as was a 12lead ECG. CT of the head and neck with angiogram showed a hypoplastic left vertebral artery. Cranial MRI showed a T2 and fluidattenuated inversion recovery hyperintense lesion on the inferior lateral right bulbar region (figures 1 and 2), with restricted diffusion pattern (figure 3). Blood tests, including Rapid Plasma Reagin (RPR) and haemoglobin A1c levels, 24hour Holter and transthoracic echocardiogram were normal. Doppler ultrasound of the cervical vessels was negative for subclavian steal syndrome or arterial dissection. Acute stroke from occlusion of the right posterior inferior cerebellar artery (PICA) was diagnosed. Clinical presentation was compatible with Wallenberg syndrome (WS). The patient showed almost complete resolution of his neurologic symptoms during admission. Syncope is a form of transient and selflimited lossofconsciousness caused by abrupt drop in cerebral blood flow, more specifically to the brainstem’s reticular activating system. Major causes of syncope are reflexmediated, such as vasovagal or carotid sinus hypersensitivity, orthostatic hypotension and cardiogenic . Although it results from brain hypoperfusion, stroke is only rarely the true cause of syncope, as the brain has a very redundant blood supply. One notable exception is the subclavian steal syndrome, which results in vertebrobasilar ischaemia during arm exercise due to subclavian artery stenosis. Stroke should be considered a cause of syncope when persistent and significant neurological changes occur before the episode or during the recovery period. WS, also known as lateral medullary syndrome, is the most prevalent posterior ischaemic stroke syndrome. It commonly results from occlusion of the PICA or one of its branches. It is characterised by crossed thermoalgic hypoesthesia, ipsilateral cerebellar ataxia, vertigo, bulbar palsy and Horner’s syndrome. Clinical presentation varies, often resulting in any combination of these symptoms. A wide range of unusual presentations of WS,