Recurrent Syncope Due to Orthostatic Hypotension Following Lateral Medullary Infarction: A Case Report

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Lateral medullary infarction with orthostatic hypotension (n=1). Intervention: Sequential treatment with midodrine, fludrocortisone, and droxidopa. Primary outcome: Resolution of recurrent syncope.

Junichi Matsuo; Keiichi Nakahara; Mitsuharu Ueda

doi:10.2169/internalmedicine.7325-26

January 1, 2026Internal MedicineOpen Access

Recurrent Syncope Due to Orthostatic Hypotension Following Lateral Medullary Infarction: A Case Report

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Key result

Sequential midodrine, fludrocortisone, and droxidopa completely resolves recurrent orthostatic syncope after lateral medullary infarction.

n=1

Why the study?

Orthostatic hypotension is not generally considered a typical manifestation of lateral medullary infarction but may cause syncope, requiring further clinical attention.

Key Points

To describe the clinical presentation, autonomic testing findings, and pharmacologic management of recurrent syncope caused by severe neurogenic orthostatic hypotension following acute lateral medullary infarction.
Clinical evaluation and management of a 77-year-old man presenting with acute right lateral medullary infarction and recurrent syncope upon early mobilization.
Autonomic and hemodynamic assessments including bedside orthostatic blood pressure measurements, plasma norepinephrine testing, and serial head-up tilt testing on hospital days 15 and 43.
Discontinuation of potentially offending antihypertensive medications alongside nonpharmacologic measures and sequential pharmacotherapy with midodrine, fludrocortisone, and droxidopa.
Initial head-up tilt testing on day 15 confirmed neurogenic orthostatic hypotension, with systolic blood pressure falling from 158 mmHg to a nadir of 74 mmHg at 50° tilt, heart rate rising minimally from 58 to 64 bpm, and plasma norepinephrine increasing inadequately from 275 to 339 pg/mL.
Syncopal episodes resolved by day 33 following sequential therapy with midodrine, fludrocortisone, and droxidopa.
Repeat head-up tilt testing on day 43 showed persistent orthostatic hypotension (systolic drop from 157 to 83 mmHg) but an improved compensatory heart rate response (from 59 to 86 bpm) without syncope, and the patient remained symptom-free at 3-month follow-up on droxidopa (300 mg/day).

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

A 77-year-old man who developed recurrent syncope due to severe orthostatic hypotension during early mobilization following an acute right lateral medullary infarction.

I

Intervention

Sequential treatment with midodrine, fludrocortisone, and droxidopa, along with nonpharmacologic measures and discontinuation of silodosin, amlodipine, and irbesartan.

O

Outcome

Resolution of orthostatic symptoms, syncope, and improvement in orthostatic hemodynamic responses assessed by serial head-up tilt testing.

Orthostatic hypotension should be recognized as a potentially treatable cause of syncope following lateral medullary infarction, and can be managed effectively with medication adjustments, vasopressors, and serial tilt testing.

Limitations

Follow-up brain MRI was not performed during the subacute phase, precluding evaluation of radiological changes corresponding to clinical improvement.
The precise pathophysiology of orthostatic hypotension and the relative contributions of medullary lesions, pre-existing diabetic neuropathy, and concomitant medications could not be fully determined.
Comprehensive autonomic testing beyond serial head-up tilt testing, including CVR-R and sudomotor testing, was not conducted.
Follow-up brain MRI was not performed during the subacute phase.
Comprehensive autonomic testing beyond serial head-up tilt testing was not conducted.

Implication

May guide refractory post-stroke orthostatic syncope management; hypothesis-generating and requires prospective validation.

Abstract

Lateral medullary infarction typically presents with sensory disturbance, cerebellar ataxia, and Horner's syndrome, whereas orthostatic hypotension is not generally considered a typical manifestation, but it may cause syncope. A 77-year-old man developed recurrent syncope during early mobilization following an acute right lateral medullary infarction. Head-up tilt testing demonstrated severe orthostatic hypotension with minimal heart rate response and inadequate plasma norepinephrine increase. Sequential treatment with midodrine, fludrocortisone, and droxidopa resolved the symptoms. Serial head-up tilt testing suggested a partial improvement in the orthostatic hemodynamic responses. Orthostatic hypotension should be considered in patients with lateral medullary infarction and positional symptoms, and serial head-up tilt testing may help document any changes in the orthostatic hemodynamic response.

Discussion

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Cite This Study

Matsuo et al. (2026) conducted a case report in Lateral medullary infarction with orthostatic hypotension (n=1). Sequential treatment with midodrine, fludrocortisone, and droxidopa was evaluated on Resolution of recurrent syncope. Sequential treatment with midodrine, fludrocortisone, and droxidopa completely resolved recurrent orthostatic syncope following a lateral medullary infarction.

synapsesocial.com/papers/6ad0fcc53afa093ea9acffd1 https://doi.org/10.2169/internalmedicine.7325-26

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Recurrent Syncope Due to Orthostatic Hypotension Following Lateral Medullary Infarction: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Recurrent Syncope Due to Orthostatic Hypotension Following Lateral Medullary Infarction: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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