Gomez Jose Ernesto, Ho Eric Justin
Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
Int J Emerg Med. 2024 Oct 7;17(1):144. doi: 10.1186/s12245-024-00709-y.
Lateral Medullary Syndrome (LMS) is a posterior circulation stroke (PCS) that has a broad array of manifestations but most classically presents with Horner's syndrome, ipsilateral ataxia, and ipsilateral hyperalgesia. Although dysphagia is also common, isolated and single presentation of this alone is rare and there are only a few case reports of this in the literature. This presentation can bias a clinician's differential diagnosis and delay diagnosis.
A previously healthy 53-year-old-male presented with a complaint of dysphagia. He had no PCS symptoms, a National Institute of Health Stroke Scale (NIHSS) of zero, and an otherwise unremarkable neurological exam. Stroke imaging including non-contrast computed tomography (NCCT) scan of his head and computed tomography angiography (CTA) scan of his head and neck revealed no acute abnormalities. He was found to be positive for Influenza A, but otherwise all other etiologies for his dysphagia were worked up, including consultation with other specialty services, without resolve. Two days later, the patient subsequently developed new right sided sensory deficits and left sided Horner's syndrome, in which a magnetic resonance imaging (MRI) scan of his head revealed an acute infarct of the left lateral medulla with likely thrombus in the left posterior inferior cerebellar artery (PICA).
PCS is frequently missed due to the often-vague symptoms and reassuring negative imaging. This case highlights the variability of presentations that ED physicians may encounter. Nonetheless, a high index of suspicion for PCS should be maintained even in young patients without risk factors. Lastly, dysphagia is never normal, and this case demonstrates the need to reconsider neurogenic origin when other causes have been ruled out.
延髓外侧综合征（LMS）是一种后循环卒中（PCS），有广泛的临床表现，但最典型的表现是霍纳综合征、同侧共济失调和同侧痛觉过敏。虽然吞咽困难也很常见，但仅以此单一症状孤立出现的情况很少见，文献中仅有少数病例报告。这种表现可能会使临床医生的鉴别诊断产生偏差并延误诊断。
一名53岁的既往健康男性因吞咽困难前来就诊。他没有PCS症状，美国国立卫生研究院卒中量表（NIHSS）评分为零，神经系统检查其他方面也无异常。包括头部非增强计算机断层扫描（NCCT）以及头部和颈部计算机断层血管造影（CTA）在内的卒中影像学检查均未发现急性异常。发现他甲型流感检测呈阳性，但对他吞咽困难的所有其他病因都进行了排查，包括咨询其他专科服务，但问题仍未解决。两天后，患者随后出现了新的右侧感觉障碍和左侧霍纳综合征，头部磁共振成像（MRI）扫描显示左侧延髓急性梗死，左侧小脑后下动脉（PICA）可能有血栓形成。
由于症状往往模糊不清且影像学检查结果阴性易让人放心，PCS常常被漏诊。本病例突出了急诊医生可能遇到的临床表现的多样性。尽管如此，即使是没有危险因素的年轻患者，也应保持对PCS的高度怀疑。最后，吞咽困难绝非正常现象，本病例表明，当其他病因被排除后，需要重新考虑神经源性病因。
