What are the signs of a medulla stroke?

Signs of Medulla Stroke

Medullary strokes present with distinct clinical manifestations that require prompt recognition for timely intervention and improved outcomes. Recognizing these signs is crucial as early diagnosis can significantly impact patient survival and quality of life 1.

Key Clinical Manifestations of Medullary Stroke

Lateral Medullary Syndrome (Wallenberg Syndrome)

This is the most common form of medullary stroke and presents with:

• Vertigo, dizziness, and vomiting 2
• Dysphagia (difficulty swallowing) and dysarthria (slurred speech) 2
• Ipsilateral ataxia (coordination problems on the same side as the lesion) 2
• Horner's syndrome (ptosis, miosis, anhidrosis) 2
• Contralateral hemiparesis (weakness on opposite side of body) 2
• Hiccups, which can be a distinctive feature 2
• Sensory deficits with loss of pain and temperature sensation on ipsilateral face and contralateral body 2

Medial Medullary Syndrome

Though rarer than lateral medullary syndrome, it presents with:

• Contralateral hemiparesis with face usually spared (due to corticospinal tract involvement) 3
• Contralateral loss of vibration and position sense (due to medial lemniscus involvement) 3
• Ipsilateral tongue weakness and deviation (due to hypoglossal nerve involvement) 3
• Tingling sensation with decreased vibration and position sense 3

Bilateral Medullary Stroke

This is an extremely rare but catastrophic form presenting with:

• Quadriplegia (weakness in all four limbs) 4
• Progressive generalized weakness 4
• Respiratory failure requiring ventilatory support 4
• Severe dysarthria 4
• Acute vertigo that may initially be misdiagnosed as vestibular syndrome 4

Diagnostic Approach

Immediate Recognition Using FAST

• Face: Look for facial drooping or asymmetry 5, 1
• Arm: Check for arm weakness or drift 5, 1
• Speech: Note any slurred speech or language difficulties 5, 1
• Time: Record when symptoms began (critical for treatment decisions) 1

Risk Stratification

Patients presenting with the following symptoms within 48 hours should be considered at highest risk:

• Unilateral weakness (face, arm, and/or leg) 5
• Language or speech disturbance 5
• Posterior circulation symptoms (diplopia, dysarthria, dysphagia, ataxia) 5

Clinical Pearls and Pitfalls

• Diagnostic Challenge: Medullary strokes, especially bilateral ones, can be misdiagnosed as acute vestibular syndrome due to prominent vertigo 4
• Imaging Considerations: Initial MRI may appear normal or show only subtle changes; a repeat MRI with diffusion-weighted imaging may be necessary 4
• Anatomical Basis for Rarity: Medial medullary syndrome is particularly rare due to an intraparenchymal network of anastomoses that provides collateral blood flow 6
• Prognosis Variation: Unilateral medial medullary syndrome generally has a better prognosis than bilateral involvement, which can be life-threatening 3
• Pediatric Considerations: Though extremely rare in children, medullary strokes can cause severe dysphagia requiring intensive intervention 7

Emergency Response

When medullary stroke is suspected:

• Activate emergency medical services immediately 5, 1
• Note exact time of symptom onset 1
• Provide supplementary oxygen if saturation is <94% 1
• Transport to a facility capable of advanced stroke care with immediate brain imaging 5

Early recognition of these distinctive signs of medullary stroke is essential for timely intervention and improved outcomes, particularly given the potential severity of these rare but significant stroke syndromes.