Management of Medial Medullary Syndrome
The management of medial medullary syndrome should focus on acute stroke treatment protocols, including timely reperfusion therapy if eligible, followed by comprehensive secondary stroke prevention measures and rehabilitation.
Medial medullary syndrome (also known as Dejerine syndrome) is a rare stroke syndrome resulting from infarction of the medial medulla. It typically presents with the classic triad of:
- Contralateral hemiparesis (affecting upper and lower extremities)
- Contralateral loss of vibration and proprioception
- Ipsilateral tongue weakness (hypoglossal nerve palsy)
Acute Management
Initial Assessment and Stabilization
- Secure airway, breathing, and circulation
- Perform rapid neurological assessment using stroke scales
- Obtain immediate brain imaging (MRI is superior to CT for brainstem lesions)
- Assess for "heart-shaped" hyperintensity at the rostral medulla on MRI, characteristic of bilateral medial medullary infarction 1
Reperfusion Therapy
- Administer intravenous thrombolysis if patient presents within the therapeutic window (typically 4.5 hours) and has no contraindications
- Consider endovascular thrombectomy if large vessel occlusion is identified (typically vertebral artery or one of its branches) 2
Medical Management
- Blood pressure management according to stroke protocols
- Maintain euglycemia
- Prevent and treat complications such as aspiration pneumonia (due to dysphagia)
- Monitor for respiratory compromise, as bilateral medial medullary infarction can affect respiratory function
Secondary Prevention
Antiplatelet Therapy
- Initiate antiplatelet therapy (aspirin, clopidogrel, or combination therapy based on individual risk factors)
- For cardioembolic sources, anticoagulation with vitamin K antagonists (target INR 2-3) is recommended
Risk Factor Modification
- Aggressive management of hypertension, as it is closely associated with medial medullary syndrome 3
- Treat dyslipidemia with high-intensity statin therapy
- Optimize diabetes management
- Smoking cessation counseling
- Weight management and lifestyle modifications
Rehabilitation
Early Rehabilitation
- Begin rehabilitation as soon as the patient is medically stable
- Address specific deficits:
- Physical therapy for hemiparesis
- Occupational therapy for activities of daily living
- Speech therapy for dysarthria and dysphagia
- Specialized therapy for proprioceptive deficits
Long-term Considerations
- Spasticity management (may develop over time) 4
- Assistive devices for mobility and activities of daily living
- Psychological support for adjustment to disability
Prognosis and Follow-up
- Medial medullary syndrome has a worse prognosis compared to lateral medullary syndrome, with higher incidence of bilateral involvement 3
- Regular follow-up to monitor neurological recovery and adjust rehabilitation strategies
- Surveillance for recurrent stroke with periodic vascular imaging
Special Considerations
- Young patients with medial medullary syndrome should undergo comprehensive workup for uncommon etiologies, including:
- Arterial dissection
- Vasculitis
- Hypercoagulable states
- Drug abuse (can cause talc embolism) 4
- Diagnostic challenges exist as this syndrome can mimic other neurological conditions such as Guillain-Barré syndrome or myasthenic crisis 1
The management approach should be coordinated through a specialized stroke center with neurological expertise, given the rarity and complexity of this condition.