Bilaterally persistent horizontal gaze palsy and facial palsy caused by pontine infarction

Case report: Lateral medullary syndrome with eight-and-a-half syndromes

RATIONALE

Lateral medullary syndrome is caused by atherosclerosis or embolism of the vertebral artery and its branches or the posterior inferior cerebellar artery (PICA).The eight-and-a-half syndrome is a rare pontocerebellar nerve-ocular syndrome presenting as a one-and-a-half syndrome plus ipsilateral seventh cerebral nerve palsy. The dorsolateral medullary syndrome combined with the eight-and-a-half syndromes is even rarer, so it is important to recognize the features of the classical brainstem syndrome and the eight-and-a-half syndromes.

PATIENT CONCERNS

Most patients with dorsolateral medullary syndrome combined with eight-and-a-half syndromes have a good prognosis, with recovery occurring within a few weeks to a few months, although a few patients may take longer to recover.

DIAGNOSIS INTERVENTIONS

In the course of disease development, the patient developed dysarthria, dysphagia, hypothermia, ipsilateral Horner sign and ataxia. Computed tomography was performed which showed cerebral infarction in the left brainstem. Cranial diffusion-weighted imaging + magnetic resonance angiography showed acute infarction in the left cerebellar hemisphere, with a high probability of severe stenosis or occlusion in the intracranial and proximal segments of the basilar arteries. This supports the diagnosis of dorsolateral medullary syndrome. The patient's limited adduction and abduction of the left eye and limited adduction of the right eye, combined with peripheral paralysis of the affected lateral nerve, supported the diagnosis of eight-and-a-half syndromes. The administration of antiplatelet and anti-ester fixation treatment can effectively improve the symptoms and shorten the course of the disease.

OUTCOMES

After antiplatelet and anti-ester fixation treatment, the symptoms improved and the patient was discharged.

LESSONS

Dorsolateral medullary syndrome combined with eight-and-a-half syndromes is a rare clinical condition, and therefore more attention should be paid to the early diagnosis and treatment of such patients.

Modified hypoglossal-facial nerve anastomosis for peripheral-type facial palsy caused by pontine infarction: A case report and literature review

Background

Peripheral-type facial palsy could be caused by a lesion in the tegmentum of the pons, such as infarction, with a rare occurrence. We herein described a case of unilateral peripheral-type facial palsy induced by dorsolateral pontine infarction and treated this patient using modified hypoglossal-facial nerve anastomosis.

Case presentation

A 60-year-old female presented with dizziness, hearing drop, diplopia, and peripheral-type facial palsy. Brain Magnetic Resonance Imaging showed a dorsolateral pontine infarction on the right side which exactly refers to the location of the ipsilateral facial nucleus or facial nerve fascicles at the pons. Subsequent electrophysiological examinations confirmed poor facial nerve function of this patient and modified hypoglossal-facial nerve anastomosis was then performed.

Conclusions

This case reminded medical practitioners not to ignore the possibility of involvement of a central cause in peripheral-type facial palsy patients. In addition, modified hypoglossal-facial nerve anastomosis served as a useful skill improvement that may help reduce hemiglossal dysfunction while restoring facial muscle function.

Complete Horizontal Gaze Paresis Due to Medial Pontine Haemorrhage

We report a case of bilateral horizontal conjugate gaze palsy due to a dorsal median pontine haemorrhage. The development of horizontal gaze palsy has been attributed to lesions in the pontine tegmentum, and in this case, has occurred in conjunction with other features as part of Foville's syndrome. Complete horizontal gaze palsy is a rare clinical manifestation as bilateral involvement is unusual. Our case provides further insight into the intricacies of the brainstem neuroanatomy through a description of the involved neural pathways and nuclei accounting for complex neurological manifestations in one patient.

Symptoms and probabilistic anatomical mapping of lacunar infarcts

Background

The anatomical distribution of acute lacunar infarcts has mainly been studied for supratentorial lesions. In addition, little is known about the association with distinct stroke symptoms, not summarized as classical lacunar syndromes. We aimed to describe the spatial lesion distribution of acute supra- and infratentorial lacunar infarcts and their association with stroke symptoms in patients eligible for thrombolysis.

Methods

All patients enrolled in the WAKE-UP trial (efficacy and safety of magnetic resonance imaging [MRI]-based thrombolysis in wake-up stroke) were screened for lacunar infarcts on diffusion-weighted imaging (DWI). The relationship between the anatomical distribution of supra- and infratentorial lacunar infarcts, their demographic characteristics and acute stroke symptoms, defined by the National Institutes of Health Stroke Scale (NIHSS) score, were correlated and compared.

Results

Maps of lesion distribution from 224 lacunar infarct patients (76 [33.9%] females, mean age [standard deviation] of 63.4 [11.5] years) were generated using computational image mapping methods. Median infarct volume was 0.73 ml (interquartile range [IQR] 0.37–1.15 ml). Median NIHSS sum score on hospital arrival was 4 (IQR 3–6). 165 (73.7%) patients had lacunar infarcts in the supratentorial deep white or grey matter, while 59 (26.3%) patients had infratentorial lacunar infarcts. Patients with supratentorial lacunar infarcts presented with a significantly lower occurrence of deficits in the NIHSS items gaze (p < 0.001) and dysarthria (p = 0.008), but had more often a paresis of the left arm (p = 0.009) and left leg (p = 0.068) compared to patients with infratentorial infarcts.

Conclusions

The anatomical lesion distribution of lacunar infarcts reveals a distinct pattern and supports an association of localization with different stroke symptoms.

Trial registration

NCT01525290.

Case Report: Bilateral Horizontal Gaze Palsy (1 + 1 Syndrome): A Supranuclear Gaze Palsy

SIGNIFICANCE

A rare case of bilateral horizontal gaze palsy with intact vertical gaze eye movements and largely intact vestibulo-ocular reflex is presented owing to demyelinating lesions of the patient's bilateral paramedian pontine reticular formations and left infranuclear abducens nerve from the patient's recently diagnosed multiple sclerosis.

PURPOSE

The purpose of this study was to report on a rare case of bilateral horizontal gaze palsy from a supranuclear lesion in a patient with a recent diagnosis of multiple sclerosis.

CASE REPORT

A 43-year-old African American woman presented urgently for evaluation of her inability to move her eyes into either horizontal gaze. Vertical conjugate movements remained intact, as did three of four extraocular muscles with horizontal vestibulo-ocular reflex testing, suggesting a supranuclear palsy. Magnetic resonance imaging revealed two demyelinating lesions in her inferior pons, which spared her nuclear and internuclear horizontal gaze pathways, as well as three of four extraocular muscles of her infranuclear horizontal gaze pathway as evidenced by her largely intact vestibulo-ocular reflex. This suggested bilateral paramedian pontine reticular formation lesions (supranuclear) and a mild left abducens nerve palsy (infranuclear).

CONCLUSIONS

Close evaluation of extraocular motilities and a solid understanding of the supranuclear, nuclear, internuclear, and infranuclear components of the horizontal gaze pathway can help identify challenging gaze palsies when encountered in a clinical setting. Appropriate neuroimaging can then be performed with an emphasis on the suspected location of the lesion(s) based on the patient's clinical findings.

Eight-and-a-Half Syndrome: A Combination of Intracranial Capillary Telangiectasia and Hematencephalon

Eight-and-a-half syndrome, a combination of one-and-a-half syndrome and ipsilateral facial palsy, was first described by Eggenberger in 1998. Intracranial capillary telangiectasia (ICT) is a rare type of latent cerebral vascular malformation characterized by a number of small, dilated, and thin-walled blood capillaries with normal brain tissues between them. Susceptibility weighted imaging is the recommended diagnostic method to detect ICT. Oommen once reported 1 case about pontine hemorrhage causing Fisher one-and-a-half syndrome with facial paralysis. Here, we report a case with regard to pontine tegmentum ICT and hematencephalon presenting as eight-and-a-half syndrome.

Eight-and-a-half syndrome caused by a pontine haemorrhage: a case report and review of the literature

BACKGROUND

Eight-and-a-half syndrome is caused by a lesion in the dorsal tegmentum of the caudal pons involving parapontine reticular formation and median longitudinal fasciculus, as well as the nucleus and/or the fasciculus of the facial nerve. It is characterized by one-and-a-half syndrome and an ipsilateral cranial nerve VII palsy. Also, many variants of eight-and-a-half syndrome have been described, including nine syndrome, thirteen-and-a-half syndrome and fifteen-and-a-half syndrome.

METHODS

We describe a case of a 49-year-old man who presented with eight-and-a-half syndrome combined with contralateral hemiparesis. We reviewed the literature describing the related spectrum of eight-and-a-half syndrome associated with various etiologies.

RESULTS

Brain computed tomography scan revealed a hyperdensity located in the left paramedian aspect of the dorsal pons. T2-weighted magnetic resonance imaging at the 11-month follow-up showed hyperintensity and enlargement of the inferior olivary nuclei, which were compatible with a diagnosis of hypertrophic olivary degeneration. In light of our observations and cases reported in the literature, we categorize the spectrum of eight-and-a-half syndrome into three types, namely classic eight-and-a-half syndrome, eight-and-a-half syndrome variants and eight-and-a-half plus syndrome. Besides, the clinical feature and outcome of the three types are discussed in this article.

CONCLUSIONS

Recognition of the spectrum of eight-and-a-half syndrome allows precise anatomic localization of the lesion to pontine tegmentum region.

Eyes and stroke: the visual aspects of cerebrovascular disease

A large portion of the central nervous system is dedicated to vision and therefore strokes have a high likelihood of involving vision in some way. Vision loss can be the most disabling residual effect after a cerebral infarction. Transient vision problems can likewise be a harbinger of stroke and prompt evaluation after recognition of visual symptoms can prevent future vascular injury. In this review, we discuss the visual aspects of stroke. First, anatomy and the vascular supply of the visual system are considered. Then, the different stroke syndromes which involve vision are discussed. Finally, topics involving the assessment, prognosis, treatment and therapeutic intervention of vision-specific stroke topics are reviewed.