What is the treatment and management approach for a patient diagnosed with lateral medullary syndrome, a stroke condition affecting the lateral part of the medulla oblongata?

Lateral Medullary Syndrome: Treatment and Management

Immediate Management

Patients with lateral medullary syndrome require urgent hospitalization with antiplatelet therapy, anticoagulation (typically low molecular weight heparin), and supportive care targeting specific neurological deficits. 1, 2

Acute Phase Treatment (First 24-72 Hours)

• Antiplatelet therapy: Aspirin 300 mg should be initiated immediately upon diagnosis 1
• Anticoagulation: Low molecular weight heparin (60 mg subcutaneously) is recommended in the acute phase 1, 2
• Neuroprotective agents: Should be administered as part of standard acute stroke management 1
• Blood pressure control: Antihypertensive treatment is essential, particularly in patients with uncontrolled hypertension 1

Diagnostic Confirmation

Brain MRI with diffusion-weighted imaging (DWI) is the gold standard diagnostic tool and must be obtained urgently. 1, 3 The ACR guidelines emphasize that thin-section coronal DWI can detect nearly 25% more acute brainstem infarcts than standard axial DWI, though false-negative results can occur with very small ischemic brainstem infarcts 4.

• CT scanning should NOT be routinely ordered as initial imaging, as posterior fossa ischemic strokes are difficult to detect on CT with sensitivity as low as 10% 5
• MR angiography should be included to evaluate for vertebral artery stenosis or occlusion 2
• Vertebral artery imaging is critical because lateral medullary infarction is strongly associated with vertebral artery dissection 3

Specific Symptom Management

Dysphagia and Aspiration Risk

• Swallowing assessment must be performed immediately, as dysphagia occurs when cranial nerves IX and X nuclei are affected 5, 4
• Gastrostomy tube placement may be necessary for patients with severe dysphagia who cannot safely maintain oral intake 6
• NPO status should be maintained until formal swallowing evaluation confirms safety

Vertigo and Ataxia

• Vestibular symptoms result from lateral medullary lesions affecting vestibular structures 5, 4
• Antiemetics for associated nausea and vomiting 1
• Physical therapy should begin early for ipsilateral ataxia 1, 7

Horner's Syndrome

• Ipsilateral ptosis and miosis are common findings requiring no specific treatment but confirm the diagnosis 1, 3, 7

Sensory Deficits

• Crossed hemisensory disturbance (ipsilateral facial sensory loss with contralateral body sensory loss) is characteristic 3
• Pain management may be needed for dysesthetic sensations 4

Monitoring for Complications

Cardiac Complications

• Electrocardiogram and continuous cardiac monitoring are essential, as atrial fibrillation can develop during hospitalization 6
• Echocardiography should be performed to evaluate for cardioembolic sources 1

Extension of Infarction

• Serial neurological examinations to detect caudal extension to pyramidal tracts, which may cause contralateral hemiparesis 7
• Repeat imaging if clinical deterioration occurs 2

Rehabilitation Phase

Early physical rehabilitation is critical and should begin within 6 days of symptom onset once the patient is medically stable. 1

• Multidisciplinary rehabilitation including physical therapy, occupational therapy, and speech therapy 6
• Dysphagia therapy with gradual advancement of diet as tolerated 6
• Gait training for ataxia and balance deficits 1

Prognosis and Recovery Timeline

Most patients with lateral medullary syndrome have a favorable prognosis with recovery occurring within weeks to months if early hospitalization and treatment are applied. 1, 2 Dysarthria and dysphagia often improve dramatically within the first week of treatment 1. However, some patients may require longer recovery periods, particularly those with extensive infarctions 2.

Critical Pitfalls to Avoid

• Do not rely on CT alone: Posterior fossa strokes are notoriously difficult to visualize on CT, and MRI with DWI is mandatory 5, 1
• Do not miss vertebral artery dissection: This is a critical association that requires specific vascular imaging 3
• Do not overlook dysphagia: Aspiration pneumonia is a preventable complication with proper swallowing assessment 6
• Do not delay antiplatelet therapy: Early initiation improves outcomes 1, 2

Long-term Secondary Prevention

• Antiplatelet therapy continuation (typically aspirin or clopidogrel) 1
• Risk factor modification: Aggressive blood pressure control, smoking cessation, and management of atherosclerotic risk factors 1, 3
• Follow-up imaging to assess for recurrent stenosis or progression of vascular disease 2