Variant Lateral Medullary Syndrome in a Patient Presenting With Inability to Swallow

A 55-year-old man with hypertension was drinking a soda when he felt a sudden “hot flash” and began gagging.  Unable to finish his drink or even swallow his own saliva, he presented to the emergency department with dysphagia as his sole complaint. His examination showed left-sided ptosis, absent gag reflex, and decreased sensation to pinprick on the right side of his face, arm, and down to the T8 dermatome on the right side of his chest. Magnetic resonance imaging showed a left lateral medullary infarction (Figure 1). This case illustrates an atypical variant lateral medullary syndrome with contralateral face, arm, and trunk sensory loss (Figure 2). The unusual pattern of sensory loss is likely due to selective involvement of the ventromedial portion of the lateral medulla, involving the ascending secondary trigeminal tract and medial spinothalamic tract. The leg sensory fibers, which have a more lateral somatotopic distribution, were spared.^1,2

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Figure 1.

Diffusion-weighted magnetic resonance image (MRI) taken on admission revealing a left medullary infarction.

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Figure 2.

Resulting area of sensory loss (gray) in the right face, arm, and trunk.