What is the treatment for acute lateral medullary syndrome?

Treatment of Acute Lateral Medullary Syndrome

Acute lateral medullary syndrome (Wallenberg syndrome) should be treated as an ischemic stroke with immediate antiplatelet therapy (aspirin 300 mg), low molecular weight heparin (60 mg subcutaneously), neuroprotective agents, and aggressive management of vascular risk factors, particularly hypertension. 1

Acute Phase Management

Immediate Stroke Protocol

• Administer aspirin 300 mg immediately upon diagnosis to prevent thrombus propagation 1
• Start low molecular weight heparin 60 mg subcutaneously for acute anticoagulation 1
• Initiate neuroprotective agents as part of standard stroke care 1
• Control blood pressure aggressively, as uncontrolled hypertension is a major risk factor 1

Diagnostic Confirmation

• Brain MRI with diffusion-weighted imaging is the most useful diagnostic tool and should be obtained urgently to confirm lateral medullary infarction 1, 2
• Perform magnetic resonance angiography to evaluate for vertebral artery or posterior inferior cerebellar artery (PICA) occlusion or dissection 3
• Vertebral artery dissection is commonly associated with lateral medullary syndrome and must be identified, as it influences management 2

Symptom-Specific Management

Dysphagia Management

• Assess swallowing function early, as dysphagia occurs commonly and increases risk of aspiration pneumonia 4
• Consider videofluoroscopic swallow study or fiberoptic endoscopic evaluation of swallowing to guide feeding decisions 4
• For severe dysphagia, tube feeding may be required for weeks to months 4
• Apply general dysphagia rehabilitation techniques used in stroke patients 4
• For refractory cases with cricopharyngeal dysfunction, consider botulinum toxin injection, balloon catheter dilatation, or myotomy 4

Vertigo and Vestibular Symptoms

• Treat acute vertigo with antiemetic medications as needed 1
• Vestibular rehabilitation should be initiated once the acute phase stabilizes 4

Hospital Course and Monitoring

• Admit to neurology ward for close monitoring of neurological status and swallowing function 1
• Monitor for complications including aspiration pneumonia, malnutrition, and progression of neurological deficits 4
• Duration of hospitalization typically ranges from 6 days to several weeks depending on severity 1

Prognosis and Rehabilitation

• Most patients have a favorable prognosis with early hospitalization and treatment, with significant improvement occurring within days to weeks 1, 3, 2
• Symptoms such as dysarthria and dysphagia often resolve within the first week of treatment 1
• Recovery may take weeks to months, with some patients requiring longer rehabilitation periods 3
• Discharge to physical rehabilitation is essential once medically stable to optimize functional recovery 1

Critical Pitfalls to Avoid

• Do not delay MRI imaging if clinical suspicion is high, as early diagnosis enables prompt antiplatelet and anticoagulation therapy 1, 2
• Do not miss vertebral artery dissection—this requires specific investigation with MRA or CT angiography 2
• Do not underestimate aspiration risk—dysphagia assessment must occur before oral intake 4
• Recognize atypical presentations, as variability in symptoms is common and may delay diagnosis 2, 5