Effects of Interdisciplinary Rehabilitation in a Patient With Lateral Medullary Infarction: A Case Report

ABSTRACT

Lateral medullary syndrome (LMS) is commonly associated with vertebral artery strokes, characterized by varied neurological manifestations depending on the site of the lesion. We report the positive effects of interdisciplinary rehabilitation interventions in helping achieve improved functional, psychosocial, and quality of life outcomes in a patient with LMS and complex neurological disabilities.

1. Introduction

Lateral medullary syndrome (LMS) results from a vascular event in the posterolateral part of the medulla oblongata, commonly involving the occlusion of the posterior inferior cerebellar artery (PICA) or vertebral artery [1]. LMS has varied neurological manifestations including impaired pain and temperature sensation involving the ipsilateral face and contralateral body, ipsilateral Horner syndrome, dysphagia, dysarthria, dysphonia, nystagmus, vertigo, nausea, vomiting and ipsilateral limb ataxia [2]. We report a case of a 76‐year‐old male patient who presented with LMS and required inpatient rehabilitation. Further, this report aims to highlight the effects of interdisciplinary rehabilitation in minimizing the impact of his disabilities and maximizing functional independence and societal participation for this patient.

2. Case History/Examination

A 76‐year‐old male patient with a history of hypertension presented to a tertiary stroke centre in February 2025 with an acute left lateral medullary infarction (LMI). The patient had four hospital presentations within the 2 weeks prior, with a crescendo of worsening neurological symptoms including vertigo, dysarthria and mild gait ataxia. The patient was initially diagnosed with transient ischaemic attack following his first two admissions. CT angiography findings demonstrated left V4 segment vertebral artery occlusion, with left posterior cerebral artery (PCA) and PICA remaining patent from collateral right vertebral artery supply (Figure 1a). There was no demonstrable ischemia on MRI brain findings (Figure 2a). He was discharged home on high dose statin, perindopril and dual antiplatelet therapy of aspirin and clopidogrel following complete resolution of his symptoms and signs.

FIGURE 1.

CT angiography images demonstrating: (a) total left vertebral artery occlusion on first admission; (b) additional stenosis of right vertebral artery on third admission.

FIGURE 2.

MR images of posterior fossa demonstrating progression of left lateral medullary infarct on diffusion weighted imaging (DWI) from: (a) initial transient ischaemic attack on first admission; (b) small lateral left medullary infarct on third admission; (c) large lateral left medullary infarct on fourth admission.

Upon his third hospital admission, the patient experienced headache, dysarthria, dysphagia, gait ataxia and left Horner's syndrome. A repeat CT angiography revealed new stenosis of his right vertebral artery (Figure 1b), with posterior circulation perfusion mismatch in the left cerebellum on CT perfusion scan (Figure 3). The patient was commenced on 24‐h heparin infusion. MRI brain findings confirmed a small acute left LMI on diffusion weighted imaging (DWI) (Figure 2b). The patient was discharged from hospital with conservative management (aspirin and ticagrelor) and deemed a clopidogrel non‐responder.

FIGURE 3.

CT brain perfusion summary slices demonstrating mismatch of cerebral blood flow (left) and time‐to‐maximum (right) in the left cerebellum on third admission.

3. Differential Diagnosis, Investigations and Treatment

The patient represented to hospital the following day with severe dysphagia, worsening ataxia and vertigo, and was admitted to the stroke unit. Modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) were 0 and 3 respectively. Physical examination demonstrated mild dysarthria, left facial weakness, left tongue deviation, moderate dysphonia, decreased right gag reflex (CN IX, X), limited tongue protrusion (CN XII), left upper limb dysmetria and gait ataxia. Laboratory test results, including full blood count, renal and liver function tests, C‐reactive protein and thyroid function tests were within normal limits. Additional assessments including telemetry, serial electrocardiograms, and Holter results were unremarkable. MRI brain findings showed progression of the previously noted lesion, with larger area of diffusion restriction in the left posterolateral medulla on DWI (Figure 2c).

The patient failed the Acute Screening for Swallow in Stroke (ASSIST) screening tool and was placed Nil by Mouth (NBM), with enteral nutrition commenced. Further evaluation of oromotor, speech and swallowing functions identified mild flaccid dysarthria, moderate dysphonia and significant oropharyngeal dysphagia, with secretion management difficulties (pooling of oral secretions, incomplete volitional pharyngeal swallow initiation and weak ineffective volitional cough). Fibreoptic Endoscopic Evaluation of Swallow (FEES) study performed on Day 3 of admission demonstrated severe pharyngeal dysphagia (Figure 4), with reduced pharyngeal clearance, upper esophageal sphincter (UES) dysfunction, and deep laryngeal penetration with all consistencies of food and fluids.

FIGURE 4.

FEES images demonstrating: (a) pooling of secretions in the left > right pyriform sinuses, with significantly reduced left arytenoid and vocal fold mobility on adduction; (b) severe cricopharyngeal dysfunction resulting in pyriform sinus residue on ice chips (thin fluids) and laryngeal penetration to the level of the vocal folds with no attempt to eject; (c) severe pyriform sinus residue in left lateral channel on pureed diet.

An intensive dysphagia rehabilitation program targeting hyolaryngeal elevation, pharyngeal contraction and upper esophageal sphincter (UES) opening was commenced. On Day 19 of admission, Videofluoroscopy Study (VFSS) demonstrated ongoing moderate–severe pharyngeal dysphagia, characterized by aspiration of thin and mildly thick fluids (Figure 5). The patient continued enteral feeding, with trials of mildly thick fluids and pureed diet. Dysphagia rehabilitation included ice chip trials, Chin Tuck Against Resistance (CTAR), Semi Occluded Vocal Tract (SOVT), and pitch glides. The patient was discharged from the acute stroke unit to inpatient rehabilitation at Day 24 of admission.

FIGURE 5.

Initial videofluoroscopy images demonstrating moderate–severe pharyngeal dysphagia, involving: (a) thin fluids: Post swallow aspiration due to overspill from anterior supraglottic residue; (b) mildly thick fluids: Severe pyriform sinus residue with incomplete clearance from pharynx; (c) puree diet: Severe residue build‐up post incomplete swallow in valleculae and pyriform sinus.

4. Interdisciplinary Rehabilitation

On admission to inpatient rehabilitation, the patient initially required supervision with his mobility with a walker (due to high falls risk and mild impulsivity) and required minimal assistance with his personal care tasks. He continued on nasogastric feeds. An interdisciplinary rehabilitation approach was undertaken towards addressing his impairments, activity limitations and participation restrictions. On average, he received physiotherapy twice a day, 1‐h session, 5 days a week, tailored to his symptoms and fatigue levels. The focus of physical therapy was targeted at coordination, balance, and gait retraining. This regimen involved a combination of postural control training, static and dynamic balance exercises, heel‐to‐toe balance, vestibular habituation, and stairs practice. Additionally, he received supervised strengthening and resistance training in seated, supine, or standing positions, consisting of 2 to 5 sets of exercises, 10 repetitions each. He received functional task retraining which targeted his performance within activities of daily living.

On Day 33, repeat VFSS findings demonstrated improvements in airway protection and pharyngeal clearance. The patient progressed to trials of minced and moist diet, and thin fluids. Pharmacological and behavioral approaches implemented to improve swallow function included reflux management (pantoprazole), compensatory strategies (cyclical swallowing with further hoik and swallow to clear residue from pharynx), and dysphagia rehabilitation exercises (Mendelsohn Maneuver, Shaker exercise, CTAR, Expiratory Muscle Strength Training (EMST), Masako Maneuver, SOVT, and Thermo‐Tactile Stimulation (TTS)). Intensive dysphagia rehabilitation was completed three times daily, 7 days per week. The patient also received targeted voice therapy (semi‐occluded vocal tract exercises, resonant voice therapy, vocal fold adduction exercises). On Day 38, the patient was upgraded to a soft and bite‐sized diet and his nasogastric tube was removed. On Day 52, the patient returned to unmodified oral intake. Other core components of interdisciplinary rehabilitation delivered included nutritional optimisation, sleep hygiene strategies, falls prevention strategies, energy conservation techniques, adaptive equipment prescription, and psychological support during his illness trajectory.

5. Conclusion and Results (Outcome and Follow‐Up)

After 1 month of inpatient rehabilitation, the patient demonstrated improved swallowing, balance, and gait. He made functional gains, improving from Functional Independence Measurement (FIM) scores from admission (74) to discharge (104) and The Royal Brisbane Hospital Outcome Measures for Swallowing (RBHOMS) scores from 2 (NBM) to 8 (Maintaining Oral Intake). Upon discharge from inpatient rehabilitation, he was able to meet his nutritional requirements orally and PEG insertion was not required. He was independent with his transfers and mobility unaided up to 100 m and was able to manage a flight of stairs unaided. He was independent with the majority of his personal care and light domestic activities of daily living. The implementation of minimal carer supports was important towards assisting this patient successfully transitioning home from hospital.

6. Discussion

This case highlights the complex constellation of neurological impairments and functional disabilities that can arise from LMS. The patient demonstrated a broad profile of symptom burden and sensorimotor dysfunction commonly associated with LMS, including impaired coordination, gait ataxia, progressive dysphagia with secretion management difficulties, vestibular and ocular symptoms, as well as bulbar signs. Collectively, these deficits contributed to significant functional decline in this patient, affecting independence in daily activities and participation in society.

LMS is most often attributed to thrombotic or embolic events, commonly caused by vertebral artery occlusion, large artery atherosclerosis, cardiogenic embolism or connective tissue disorders [2]. Neurological manifestations depend on the site of the lesion. Damage to the spinal trigeminal nucleus or spinothalamic tract can cause ipsilateral pain and temperature loss on the face, or contralateral loss of pain and temperature sensation in trunk and limbs. Damage to the nucleus ambiguous can cause ipsilateral dysphagia, dysarthria and dysphonia. Ipsilateral ataxia can occur with damage to the cerebellum or inferior cerebellar peduncle. The presence of vertigo and nystagmus is indicative of vestibular nuclei involvement, whilst ipsilateral Horner's syndrome can be caused by disruption of hypothalamospinal fibers. In this patient, recurrent vertigo was observed, reflecting posterior circulation involvement rather than a predictor of poor prognosis. In LMS and other posterior circulation strokes, vertigo is typically linked to non‐lacunar vertebrobasilar lesions in the cerebellum or brainstem, and is not associated with increased in‐hospital mortality or adverse outcomes at discharge [3]. The recognition of this association underscores the importance of prompt neurological assessment and imaging in patients presenting with vertigo, enabling early diagnosis and timely initiation of targeted vestibular rehabilitation.

This case also highlighted dysphagia as a predominant and clinically significant feature of LMS. Dysphagia is reported in 51%–94% of patients with LMS [4, 5], often more profound compared to cortical strokes and associated with prolonged recovery [6]. The neural control of swallowing involves the nucleus ambiguous, nucleus tractus solitarius and reticular formation, which coordinate the pharyngeal and esophageal phases [7]. Typical VFSS findings in LMS include impaired triggering of pharyngeal reflex, decreased laryngeal elevation, larger amount of residual material, delayed pharyngeal transit time and poor UES relaxation [8]. Although the prognosis for patients with LMS is usually favorable for functional outcomes, dysphagia remains clinically significant due to risks of aspiration pneumonia, malnutrition, increased mortality and extended length of hospital stay [9, 10]. In this patient, we highlighted the clinical course and outcomes of severe dysphagia in LMS, including improved VFSS findings and progression to oral feeding at 7 weeks following onset.

From a rehabilitation perspective, the management of dysphagia should be multimodal. Conventional interventions, such as task‐specific remediation exercises and compensatory strategies, remain central. Further, neuromuscular electrical stimulation (NMES) has been increasingly used to strengthen oropharyngeal muscles and improve swallowing function in post‐stroke dysphagia [11]. Early evidence suggests that NMES, when combined with conventional treatments, may accelerate recovery and improve functional outcomes [11]. In addition, non‐invasive brain stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), are emerging as adjunct therapies that can modulate cortical excitability and enhance neuroplasticity, showing potential to improve dysphagia in LMS [12]. These interventions represent promising avenues for future research and individualized care planning.

From a broader rehabilitation perspective, there remains a paucity of controlled studies and evidence‐based clinical guidelines for management of LMS, including dysphagia, making rehabilitation treatment approaches more challenging. Nevertheless, this case highlights the importance of individualized care based on disease severity, stroke guidelines and multidisciplinary input. Typically, these strategies include secondary stroke prevention through lifestyle modification, risk factor control (smoking, hypertension, blood pressure lowering medications, antithrombotic treatment, statins) and timely access to interdisciplinary rehabilitation interventions to maximize functional outcomes.

This case report has some limitations. As a single case report, the generalizability of these findings is inherently limited. Individual variations in location of stroke lesion, severity of neurological impairments and pre‐existing patient comorbidities may influence clinical presentation, progression, stroke trajectory and response to rehabilitation, making it difficult to extrapolate outcomes to all patients presenting with LMS. Additionally, the lack of a control group makes it difficult for definitive conclusions about the effectiveness of targeted interventions, including dysphagia and vestibular rehabilitation strategies. Future studies with larger cohorts or comparative methodology are needed to strengthen evidence for best management approaches in LMS.

In conclusion, the early identification and prompt management of LMS are critical in improving patient outcomes. This case demonstrated the value and benefits of interdisciplinary rehabilitation in improving physical, functional, psychosocial and quality of life outcomes for a patient with LMS, particularly in the presence of multifaceted clinical deficits and complex neurological disabilities.

Author Contributions

Krystal Song: conceptualization, data curation, writing – original draft, writing – review and editing. Mitchell D. Evans: data curation, writing – original draft, writing – review and editing. Sinead Mccaffrey: data curation, writing – original draft, writing – review and editing. Madeleine Johns: data curation, writing – original draft, writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Consent

The patient provided written informed consent for publication of the details of their medical case and any accompanying images.

Conflicts of Interest

The authors declare no conflicts of interest.

Song K., Evans M. D., Mccaffrey S., and Johns M., “Effects of Interdisciplinary Rehabilitation in a Patient With Lateral Medullary Infarction: A Case Report,” Clinical Case Reports 14, no. 1 (2026): e71804, 10.1002/ccr3.71804.

Data Availability Statement

Data can be requested from the corresponding author when required. All relevant data have been provided in the generation of this manuscript, which is intended for open access publication.