Arq. NeuroPsiquiatr. vol.30 número1

LATERAL SYNDROME OF THE MEDULLA OBLONGATA

(WALLENBERG'S SYNDROME) AS A COMPLICATION

OF A VERTEBRAL ANGIOGRAPHY. A CASE REPORT

ROBERTO MELARAGNO

A bibliographic review did not show us a case report similar to the

present one in which a medulla oblongata's lateral syndrome (Wallenberg's

syndrome) had complicated a vertebral angiography made through direct

vessel's puncture.

In the case of Sahadevan and col.

the lateral ischemia of the medulla

oblongata in a man 19 years old took place prior to the vertebral

angio-graphy and it was precisely the cause of this examination; as a

complica-tion following the mencomplica-tioned angiography, a transient cortical blindness

appeared. Incidentally, cortical blindness seems to constitute one of the

most frequent complication of vertebral angiography, either by direct

punc-ture of the vertebral vessel or by retrograde r o u t e

, or by

catheteriza-tion

.

.

; it is interesting to note that visual complications may also follow

the angiography by carotid artery (Haney and P r e s t o n

) . Other more

infre-quent forms of complications arising from vertebral angiographies may occur,

including d'rect osteolytic lesion of the vertebral b o d y

, myelomalacia of

the cervical spinal c o r d

as well as varied forms of laryngeal involvement.

Dobrek and c o l .

emphazise the possible side effects of angiographies in

patients over 50 years.

O B S E R V A T I O N

I . M . O . , a w o m a n 54 years old, B r a z i l i a n , nun. A d m i s s i o n on A u g u s t 2, 1968. In the a n a m n e s i s there are references to a s y m p t o m a t o l o g y of a simple d i v i n g goiter (October 1967), found out t h r o u g h a chest p l a n i g r a p h y . A f t e r surgery, she presented a dysphonia r e s u l t i n g from a n i n v o l v e m e n t of the left recurrent nerve, and a p p r o x i m a t e l y a t the s a m e time, h a l l u c i n a t o r y vision of objects or i m a g e s at the r i g h t fields of vision. L a t e r , these s u b j e c t i v e sensations were replaced by nondifferentiated phosphenes a n d haze, a l w a y s in the r i g h t fields of vision. O n F e b r u a r y 1st, 1968, a neuro-ophtalmologic e x a m i n a t i o n showed only a r i g h t subtotal homonymous h e m i a n o p s i a ; the v i s u a l a c u i t y w a s i n t a c t ; the p u p i l l a r y reflexes, e x t r i n sic motricity, o c u l a r pressure, corneal sensibility, eye ground, and o p h t a l m o d y n a m o -metry were n o r m a l . A t the physical examination, slight t e l a n g i e c t a s i a s in the lower limbs were observed. Blood pressure: 170 x 100. Neurological examination — N o r m a l g a i t ; m u s c u l a r s t r e n g t h preserved; R o m b e r g ' s sign absent; n o r m a l

dination; deep and superficial reflexes, n o r m a l . N o r m a l sensibility in a l l superficial a n d deep forms. A b s e n c e of sensitive p h e n o m e n a of e x t i n c t i o n . Paresis of the left v o c a l chord. R i g h t h o m o n y m o u s h e m i a n o p s i a . Electroencephalogram n o r m a l . Skull

X-Ray n o r m a l . Cerebrospinal fluid: s u b o c c i p i t a l p u n c t u r e ; i n i t i a l pressure 20 c m8

of w a t e r ; 0 cells; proteins 15 m g ; i m m u n o l o g i c a l e x a m i n a t i o n s n e g a t i v e .

O n A u g u s t 4, 1968, the p a t i e n t w a s s u b m i t t e d u n d e r g e n e r a l anesthesia to a left c a r o t i d o g r a p h y w i t h H y p a q u e as t h e contrast m e d i u m , the posterior cerebral artery beeing not visualized. A t the s a m e occasion a n a n g i o g r a p h y t h r o u g h a direct p u n c t u r e of the v e r t e b r a l a r t e r y w a s performed, both posterior cerebral a r t e -ries being visualized. T h e p u n c t u r e of the v e r t e b r a l a r t e r y w a s imperfect w i t h i n f i l t r a t i o n of the c o n t r a s t in t h e vessel's inner c o a t (fig. 1 ) . Soon after the patient presented a l a t e r a l b u l b a r syndrome ( W a l l e n b e r g ' s syndrome) at the r i g h t side (cerebellar syndrome at the r i g h t side of the body, hyposthesia w i t h severe right h e m i f a c i a l pain, delimited a t the t r i g e m i n a l area, a l t e r n a t e hyposthesia i n v o l -v i n g the r i g h t h e m i f a c e and the left side of t h e body, chiefly the upper l i m b ) . S t i l l at the r i g h t side, a C l a u d e - B e r n a r d - H o r n e r ' s syndrome a n d paresis of the p a l a t e and, at the lesser grade, of the r i g h t v o c a l chord w a s observed. T h e e v o l u t i o n of the case w a s satisfactory, a l t h o u g h the c l i n i c a l picture w a s a l w a y s e v i d e n c i n g n e u r a l g i a at the r i g h t h e m i f a c e , but not presenting the p a r o x y s m a l c h a r a c t e r i s t i c s of the classic t r i g e m i n a l n e u r a l g i a .

C O M M E N T S

This case seems to prove once more that the lateral medulla oblongata's

syndrome depends rather on the occlusion of the vertebral artery than on

the inferoposterior cerebellar artery, although this latter is directly

respon-sible for the irrigation of the ischemic area. Incidentally, this fact has

been reported by many authors during the past y e a r s

-

.

.

A n interesting aspect in this case is in connection with the possible

pathogenic mechanism of the complication occurred. Indeed, several

mecha-nisms have been considered responsible for the most varied adverse effects,

being in their majority ischemic complications caused by cerebral

angiogra-phies. I t seems that the mechanism most frequently mentioned would be

that representend by incorrect injections

.

.

,

-

.

sometimes

unavoida-ble, in the vascular wall, with dissection of the coat beneath the intima by

the contrast medium. However, other possible mechanisms could also be

responsible

: toxic effects of the contrast m e d i u m

although there is not a

necessary correlation between the volume of the contrast medium and the

frequency of complications

; aggravation of the ischemia through the

tempo-rary replacement of blood by the contrast m e d i u m

.

; hypotension during

anesthesia

; stricture provoked by the needle itself or catheter;

intravas-cular agglomeration of blood components

,

.

interfering with the

micro-circulation in the tissues, and influence on the normal standard of serum

proteins

. Complications caused by cerebral angiography would be more

frequently in older individuals

>

. In accordance with B a k e r

brain stem. In the casuistics of Petit-Dutaillis and c o l .

four severe

acci-dents were related, with two deaths in 162 vertebral angiographies.

Anyway, it has been assumed that frequency and severity of

compli-cations would be inversely proportional to the distance between the nervous

tissue and the site of injection of the contrast m e d i u m

tentative to puncture this artery, sometimes filiform, causes a greater

num-ber of defective? injections. W e think it is very probable that in the reported

case the lesion occurring in the vertebral artery has been provoked by the

angiographically verified extravasation of the contrast medium into the vessel

wall.

The complication reported constitutes one more warning to avoid the

angiography through direct puncture of the vertebral artery which, when

necessary, should be visualized throug indirect contrastation, either by

re-trograde route, through the subclavian or humeral artery, or by

catheteri-zation.

S U M M A R Y

C a s e report of a female patient, 58 years old, who, due to a right

homo-nymous hemianopsia, was submitted under general anesthesia successively to

angiographies through the right carotid and vertebral arteries. A t the first

examination no abnormalities were evidenced, but the contrast medium did

not reach the posterior cerebral artery; angiography by the right vertebral

artery, with extravasation of the contrast medium into the vessel wall,

visualized both posterior cerebral arteries. I m m e d i a t e l y after the angiographic

study, the patient presented the characteristic picture of the W a l l e n b e r g ' s

syndrome caused by involvement of the right lateral part of the medulla

oblongata. T h e evolution of the case was good, despite the residual right

hemifacial neuralgic pain. A n involvement of the vertebral artery, through

an i n t r a m u r a l injection of H y p a q u e is assumed to be the most probable

pathogenic mechanism. T h e reported complication is considered as one more

warning to prevent angiographies of the vertebral artery through direct

puncture of this vessel, due to its recognized a n a t o m i c a l variations.

R E S U M O

Síndrome lateral do bulbo (Wallenberg) como complicação de angiografia

pela artéria vertebral

injeção intramural de H y p a q u e foi considerado como o mecanismo patogênico

mais provável. A complicação registrada é considerada como u m argumento

a mais para se evitar angiografias da artéria vertebral mediante punção direta

deste vaso, devido a suas grandes variações anatômicas.

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