The Trouble with Swallowing: Dysphagia as the Presenting Symptom in Lateral Medullary Syndrome

Background: Posterior circulation strokes account for approximately one-fourth of all ischemic strokes, but are frequently misdiagnosed by emergency providers. Current standard stroke screening tools such as the National Institutes of Health Stroke Scale and the Cincinnati Prehospital Stroke Scale are weighted toward anterior circulation stroke diagnosis. Lateral medullary syndrome, a type of posterior circulation stroke, can be particularly challenging to diagnose due to nonspecific presenting symptoms, such as dysphagia. Case Report: This report describes a 65-year-old man who presented with dysphagia, dizziness, and hoarseness. An initial neurological examination did not reveal any gross deficits, and imaging to evaluate for posterior circulation stroke was not obtained. The patient presented the following day with worsening symptoms, prompting imaging that revealed a large cerebellar ischemic infarction. Why Should an Emergency Physician Be Aware of This?: Although dysphagia frequently occurs in lateral medullary syndrome, it is rarely the presenting symptom in the emergency department. In patients with cerebrovascular risk factors who present with dysphagia, a complete neurological examination should be performed and noncontrast computed tomography (CT) of the head should be obtained if a neurological deficit is appreciated. Due to their poor sensitivity, CT scans can frequently miss posterior circulation strokes, therefore magnetic resonance imaging should be considered if provider suspicion remains high. Emergency providers are encouraged to have a high level of suspicion for this rare but debilitating stroke syndrome to avoid misdiagnosis and delayed care.