From the Guidelines
Acute medullary infarction typically presents with multiple lower cranial nerve palsies, long tract signs, nystagmus, vertigo, ataxia, nausea, and vomiting, as a result of damage to the medulla oblongata and its vascular supply from the anterior spinal artery, branches of the vertebral arteries, and the posterior inferior cerebellar arteries 1. The clinical manifestations of acute medullary infarction can be variable, but often include:
- Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII) 1
- Long tract signs, which indicate damage to the brainstem and spinal cord
- Nystagmus, which is an involuntary movement of the eyes
- Vertigo, which is a sensation of spinning or imbalance
- Ataxia, which is a lack of coordination and balance
- Nausea and vomiting, which can be caused by damage to the brainstem and its connections to the gastrointestinal system These symptoms can be caused by a variety of conditions, including brainstem infarctions and hemorrhages, demyelinating disease, primary brainstem tumors, metastasis, encephalitis, Arnold-Chiari malformations, and syringobulbia 1. The diagnosis of acute medullary infarction is typically made based on a combination of clinical evaluation, imaging studies, and laboratory tests. A thorough neurologic examination can help to localize the lesion to the brainstem and identify associated signs and symptoms 1. It is essential to note that the management of acute medullary infarction focuses on immediate stroke management, secondary prevention, and supportive care, including management of dysphagia, vertigo, and pain control, as well as physical, occupational, and speech therapy 1.
From the Research
Clinical Manifestations of Acute Medullary Infarction
The clinical manifestations of acute medullary (lower brainstem) infarction can vary depending on the location and extent of the infarct. Some common manifestations include:
- Respiratory and cardiovascular complications, which can be life-threatening 2
- Breathing disorders, such as central hypoventilation or uncontrollable high-frequency tachypnea 3
- Motor paralysis and numbness, which can be severe and affect the upper limbs 4
- Pain catastrophizing and abnormal physical sensations, which can be debilitating for patients 4
- Autonomic dysfunction, which can lead to various systemic complications 2
Location-Specific Manifestations
The location of the infarct within the medulla can also influence the clinical manifestations. For example:
- Lateral medullary infarction can cause respiratory and cardiovascular complications, as well as recurrent vertebrobasilar territory strokes 2
- Medial medullary infarction can cause breathing disorders, such as uncontrollable high-frequency tachypnea, and motor paralysis 3, 4
Treatment and Management
The treatment and management of acute medullary infarction depend on the underlying cause and the severity of the symptoms. Some studies suggest that:
- Tissue plasminogen activator (t-PA) can be effective in preventing death and disability in patients with acute ischemic stroke, including those with medullary infarction 5, 6
- Novel therapies, such as imagery neurofeedback-based multisensory systems (iNems) training, may be useful in improving motor function and reducing pain catastrophizing in patients with medial medullary infarction 4