Stepwise nutritional management combined with multimodal rehabilitation for severe dysphagia following medullary infarction in an elderly patient: a case report.

Nutritional support and rehabilitative training are crucial for functional recovery in stroke patients with dysphagia. Malnutrition often aggravates motor, cognitive, and emotional deficits, underscoring the need for tailored nutritional strategies to improve swallowing and motor outcomes. We present a case of severe dysphagia complicated by secondary gastroparesis following a medullary infarction. After assessment by a multidisciplinary team (MDT), a multimodal rehabilitation protocol was implemented, consisting of repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and neuromuscular electrical stimulation (NMES), combined with conventional swallowing training. Concurrently, a structured stepwise nutritional management plan was executed, progressing from nasojejunal (NJ) feeding to intermittent oro-esophageal (IOE) tube feeding, and finally to independent oral intake. After 3 months of integrated treatment, the patient's Modified Mann Assessment of Swallowing Ability (MMASA) score improved from 81 to 94(out of 100). Videofluoroscopic Swallowing Study (VFSS) demonstrated a reduction in laryngeal elevation latency and safe pharyngeal transit, allowing for the successful removal of the feeding tube. This case suggests that MDT-guided stepwise nutritional management, when combined with multimodal swallowing rehabilitation, may offer a beneficial and feasible therapeutic approach for severe dysphagia post-medullary infarction. This integrated model successfully balances therapeutic safety with functional recovery, providing a practical framework for breaking the vicious cycle of post-stroke dysphagia and malnutrition.