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Opalski's syndrome and COVID-19: case report

RESUMO

Case report: A 64-year-old male patient was admitted at the Emergency Department in January 2022 with history of sudden onset severe headache followed by vomiting, right side hemiparesis and ipsilateral sensory loss. He didn’t receive thrombolytic therapy and showed progressively improvement of the symptoms. After two days, he developed sudden onset right hemiparesis, dysarthria, dysphagia and gait instability. The patient had a background of hypertension and epilepsy. Furthermore, the patient had symptoms of cough and fever three days previously addition and was diagnosed with COVID-19 at the hospital based on an antigen test. Neurological examination showed right side facial weakness, ipsilateral miosis and touch sensory loss. Right side arm and leg paresis was present associated with left side pain and temperature loss in trunk and limbs. He also had axial ataxia and gait instability. Characterizing a rare variant of the lateral medullary syndrome: Opalski`s syndrome. MRI revealed an acute medullary infarction on the right dorsolateral portion. Routine blood tests were normal, as were the cerebrospinal fluid, electrocardiogram and echocardiogram. CT angiography revealed hypoplasia of the right vertebral artery. The patient was managed conservatively, received secondary prophylaxis with aspirin and statin, physiotherapy and speech therapy at the stroke unit. He was referred for outpatient follow-up. Discussion: Opalski's syndrome is a rare variant of Wallenberg’s syndrome. It is usually caused by vertebral artery occlusion, compromising blood flow to the lateral region of the medulla, caudal to the pyramids decussation, leading to involvement of corticospinal and spinothalamic tracts, autonomic fibers and cranial nerves. The classical presentation is ipsilateral hemiplegia or hemiparesis, dysarthria, dysphagia, ipsilateral nystagmus, vertigo, hypoesthesia in the ipsilateral hemiface and contralateral sensory loss in trunk and limbs. It’s relevant to be familiar with the syndrome as the myriad and bilateral distribution of symptoms could lead to difficulties in topographic localization. It’s also worth mention that the recent COVID infection and hypertension were risk factors for the stroke event. Final comments: Thus, in face of sudden ipsilateral hemiparesis and cross-sensitivity alterations, this syndrome should be considered and appropriate treatment should be promptly initiated, considering the impact on survival and prevention of disabling deficits.