Abnormal brain MRI diffusion-weighted imaging in a case of Opalski syndrome.

To cite: Deshpande A, Shetty A, Pai AR, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201695 DESCRIPTION Opalski syndrome is the presence of ipsilateral hemiplegia which is associated with symptoms of a lateral medullary syndrome. Studies confirm that the infarction, in such cases, occur at lower level than that found in lateral medullary syndrome. Thus far, most cases of this syndrome reported have been attributed to vertebral artery occlusion/ stenosis, or vertebral artery dissection which compromises the medullary penetrating arteries. Meanwhile, there are two reports concerning Opalski syndrome caused by vertebral vascular compression, which mentioned that Opalski syndrome can be provoked not only by infarction, but also by medulla oblongata dysfunction caudal to the pyramidal decussation caused by vascular compression. 5 The pyramidal fibre involvement in Opalski is ipsilateral to the side of infarct as these fibres involved, are after their crossing from contralateral side at the level of lower medulla. Diffusion-weighted imaging (DWI) is a sensitive MRI sequence to detect acute infarct. However, as per the available literature, detection of this infarct so as to cause Opalski syndrome has been reported only twice before, and is extremely rare. Our patient presented with abrupt onset of the left-sided hemiparesis, headache, gait disturbance and recurrent vomiting. Neurological examination revealed left-sided hemiparesis (MRC grade 3/5 power), Left Horner’s syndrome, left upper limb incoordination, ipsilateral face decreased pin prick and contralateral body sensory affection. The patient’s left plantar was extensor. We did the bilateral carotid-vertebral Doppler, which did not show any obvious occlusion, but it did show increased pressure change in the affected vertebral suggestive of probable distal obstruction. The intracranial flow voids in the affected vertebral and basilar artery were however normal. Hence we feel vascular stenosis/occlusion is a possibility in our patient but could not be proven as MR