Clinical Localization: Déjerine's Medial Medullary Syndrome (Déjerine Anterior Bulbar Syndrome)

The tongue deviates toward the lesion side in a LMN (nuclear/fascicular) lesion. Right tongue deviation + right arm weakness = RIGHT-sided medial medullary lesion (Déjerine syndrome).

Management — Next Steps (Acute Ischemic Stroke Protocol)

STEP 1 — Immediate Stabilization (within minutes)

STEP 2 — Emergency Neuroimaging (within 25 minutes of arrival)

• Non-contrast CT head: Rule out hemorrhagic stroke — this is mandatory before any thrombolysis. CT is less sensitive for posterior fossa/brainstem infarcts.
• MRI brain with DWI (diffusion-weighted imaging): Far superior for brainstem lesions; will show restricted diffusion in the medial medulla. MRI + MRA (magnetic resonance angiography) to assess vertebral/basilar artery patency.
• CTA head + neck: If MRI not immediately available; evaluates vertebral artery occlusion (most common cause of medial medullary syndrome).

"Perform an emergency noncontrast head CT scan to differentiate between ischemic stroke and hemorrhagic stroke; there are no reliable clinical findings that conclusively separate ischemia from hemorrhage." — Harrison's Principles of Internal Medicine 22e

STEP 3 — Reperfusion Therapy (time-critical)

IV Thrombolysis — IV Alteplase (tPA)

• If within 4.5 hours of symptom onset and no contraindications → IV alteplase 0.9 mg/kg (max 90 mg); 10% as bolus, remainder over 60 min
• Pre-thrombolysis BP target: Must be <185/110 mmHg before administration (use IV labetalol or nicardipine)
• Key contraindications: Active hemorrhage, recent surgery, anticoagulant use with therapeutic INR, prior intracranial hemorrhage

Endovascular Thrombectomy (Mechanical)

• If large vessel occlusion (vertebral or basilar artery) is confirmed on CTA/MRA
• Can be considered up to 24 hours in selected patients with favorable imaging profile
• Basilar artery occlusion: thrombectomy has particular benefit given high mortality of untreated basilar occlusion

STEP 4 — Blood Pressure Management

"Blood pressure should be reduced if it exceeds 220/120 mmHg... or if blood pressure is >185/110 mmHg and thrombolytic therapy is anticipated." — Harrison's 22e

STEP 5 — Antithrombotic Therapy (if tPA not given)

• Aspirin 325 mg within 24–48 hours of stroke onset
• For minor stroke/TIA: dual antiplatelet therapy (aspirin + clopidogrel) for 21 days reduces early recurrence
• Anticoagulation (heparin): Not routinely indicated for atherothrombotic stroke; may be considered for cardioembolic stroke (AF) after ruling out hemorrhagic transformation

STEP 6 — Etiology Workup (early, guides secondary prevention)

STEP 7 — Admit to Stroke Unit / ICU

• Specialized stroke unit admission: reduces mortality, length of stay, and nursing home discharge
• Avoid hyperthermia (treat fever aggressively — worsens ischemic outcome)
• Maintain euglycemia (avoid both hypo- and hyperglycemia)
• DVT prophylaxis: pneumatic compression stockings (safe even post-thrombolysis)
• Early physiotherapy, occupational therapy, and speech pathology assessment

Summary Flowchart

Acute presentation (right arm weakness + right tongue deviation)
        ↓
Localize → Right medial medullary stroke (Déjerine syndrome)
        ↓
IMMEDIATE: ABCs, IV access, glucose, cardiac monitoring, NPO
        ↓
URGENT: Non-contrast CT head (rule out hemorrhage)
        ↓
MRI DWI / CTA head & neck (confirm infarct + identify vessel)
        ↓
TIME WINDOW CHECK:
  ≤4.5 h + no contraindications → IV Alteplase (tPA)
  Large vessel occlusion → Mechanical Thrombectomy (up to 24 h)
        ↓
BP management + Aspirin (if no tPA) + Stroke Unit admission
        ↓
Etiology workup → Secondary prevention

• Harrison's Principles of Internal Medicine 22e (2025) — Chapter 438, Acute Ischemic Stroke
• Bradley and Daroff's Neurology in Clinical Practice — Chapter 65, General Management of Acute Ischemic Stroke
• Localization in Clinical Neurology, 8e — Chapter 15, Medial Medullary Syndrome (Déjerine Anterior Bulbar Syndrome)