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A previously healthy 55 year old man presented with acute onset of nausea, vomiting, diplopia, and vertigo. He had hoarseness of voice, difficulty in swallowing, and nasal regurgitation of food and water. He had a tendency to fall to the right side. On neurological evaluation he had cerebellar type of dysarthria, right sided gaze evoked nystagmus, paralysis of palatal and pharyngeal movement, and absent gag reflex on the right side. He also had Horner’s syndrome on the right side. There was no motor weakness, deep tendon reflexes were normal, and both plantars were flexor. There was loss of pain and temperature sensations over left half of face, arm, and leg and presence of cerebellar signs on the right side. The rest of the examination including fundus was unremarkable. A provisional diagnosis of right sided lateral medullary syndrome was made. Unusually in this case, the contralateral half of face was involved. This may be due to involvement of the contralateral trigeminothalamic tract that crosses the side of the lesion within the dorsal medulla. Alternatively medullary neurons may receive input from the contralateral face. Investigations revealed high fasting (9.1 mmol/l) and postprandial (13.3 mmol/l) plasma glucose concentrations, a glycated haemoglobin of 10.5%, total cholesterol of 7.0 mmol/l, low density lipoprotein of 4.9 mmol/l, and high density lipoprotein of 0.9 mmol/l. Magnetic resonance imaging revealed a small infarct in right lateral medullary region (fig 1). The patient was managed with insulin, aspirin, and atorvastatin. His condition steadily improved over the next two weeks and he was nearly asymptomatic six months after discharge.
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