Clinical features and imaging study of brainstem infarction dominantly presented as internuclear ophthalmoplegia / 重庆医学

Objective To describe the clinical features and magnetic resonance imaging (MRl) findings of brainstem infarction producing internuclear ophthalmoplegia (INO) as an predominant clinical manifestation.Methods The clinical data of 9 patients diagnosed with brainstem infarction presenting with INO by angiography and MRI diagnosis in our hospital were collected from January 2010 to October 2016.The clinical features and imaging findings of these patients were analysed,and the pathogenesis mechanisms was analysed by literature research.Results The median age of the 9 patients was 56 years old,and there were 5 young and middle aged cases (under 60 years old),accounted for 55.6％.Among them,8 cases (88.9％) with INO typically presenting with horizontal diplopia,the most common accompanied symptom was dizzness (accounted for 55.6％),and most of them (accounted for 77.8％) were unilateral.A total of 6 cases were anterior INO,3 cases were both anterior and posterior INO.Five cases (55.6％) retained converging movement.The MRI showed that paramedian ventral infarcts located in the the cerebral aqueduct were responsible for INO in 1 case,and paramedian dorsal infarcts located in the pons were responsible for INO in 8 cases.The magnetic resonance angiography (MRA) indicated that vascular occlusion or stenosis was found in posterior circulation in 6 patients,there were 5 cases with stenosis of the posterior cerebral artery which was the most common.The ocular symptoms,including diplopia and blurred vision,of 6 cases (66.7％) disappeared during their hospital stay (range:13-23 d,median:14 d).During following up,ocular symptoms of 1 case finally disappeared within 3 months.Conclusion Brainstem infarction presenting with INO is mainly caused by paramedian dorsal infarcts located in the pons,and most of the patients complicated with posterior circulation atherosclerotic lesions.The pathogenesis varies,and the patients have a good clinical prognosis.For the young and middle-aged patients presenting with diplopia as an initial symptom,it should pay more attention to differential diagnosis.

Síndrome del uno y medio secundario a ataque cerebrovascular isquémico vertebrobasilar / One and half syndrome after ischemic vertebrobasilar stroke

El síndrome del uno y medio es una entidad que se caracteriza por parálisis de la mirada conjugada horizontal y alteración del fascículo longitudinal medial (FLM) ipsilateral secundario a diversas etiologías, entre las que se incluye el ataque cerebrovascular (ACV). Se describen dos casos de pacientes que consultaron por hemiparesia, incapacidad para realizar movimientos horizontales en uno de los ojos y abducción forzada del ojo contralateral e imposibilidad para la aducción. En ambos casos los estudios demostraron la presencia de un ACV isquémico vertebrobasilar como origen del síndrome; el reconocimiento de la fisiología de la mirada conjugada es fundamental en el abordaje del paciente y permite realizar un diagnóstico exacto a partir de una historia clínica detallada y una evaluación física minuciosa.

The One and a Half Syndrome is a condition characterized by paralysis of the horizontal conjugate gaze and a ipsilateral internuclear ophthalmoplegia secondary to other processes such as a stroke. We describe two cases of patients that had hemiparesis, inability to perform horizontal movements in one eye and forced abduction of the contralateral eye with inability to adduct it. With the corresponding study of both cases it was possible to diagnose a vertebrobasilar ischemic stroke as the origin of the syndrome; the recognition and understanding of the physiology of the conjugate gaze is crucial in the approach of the patients and allow an accurate diagnosis using a detailed history and a thorough physical evaluation.

Medial Longitudinal Fasciculus on MRI in a Patient with Internuclear Ophthalmoparesis: A Case Report

The medial longitudinal fasciculus (MLF) is myelinated composite tract, lying near the midline, ventral to periaqueductal grey matter that plays a key role in coordinating eye movements. A lesion of the MLF results in an ipsilateral adduction deficit and a contralateral abducting nystagmus, referred to as an internuclear ophthalmoparesis. The blended tract with adjacent white matter in pons and midbrain is indistinguishable on brain imaging such as CT and MRI. Until now, to the best of our knowledge, MLF is not delineated on in vivo MRI. We present a case showing the whole connecting courses of MLF lesion on MRI in a patient with inflammatory demyelinating disorder.

Bilateral ptosis and supranuclear downgaze paralysis

The purpose of this article is to highlight an uncommon combination of supranuclear downward gaze paralysis with bilateral eyelid ptosis in a 53-years-old man with a radiation induced midbrain tumor and to discuss the aspects regarding the centers and pathways that mediate supranuclear vertical gaze movements.

O objetivo deste artigo é ressaltar uma rara condição caracterizada por paralisia supranuclear do olhar conjugado para baixo associada a ptose palpebral bilateral em um homem de 53 anos, causada por tumor mesencefálico radio-induzido, e discutir os aspectos relacionados ao controle supranuclear dos movimentos oculares verticais.

A Case of Bilateral Upgaze Palsy associated with Unilateral Midbrain Hemorrhage in Moyamoya Disease

PURPOSE: To report a case of bilateral upgaze palsy associated with unilateral midbrain hemorrhage in moyamoya disease. METHODS: A 29-year-old woman presented with a sudden decrease of consciousness and was diagnosed with a spontaneous brain hemorrhage in the right side of the midbrain, right basal ganglion, and third ventricle. The mentality was improved after external ventricular drainage of hemorrhage, but bilateral upgaze difficulty remained. We performed neuro-ophthalmic and radiologic evaluation of the cause of bilateral upgaze difficulty. RESULTS: She showed a upgaze limitation of -2 grade in the right eye and -3 grade in the left eye, but normal movements in other versions and ductions. There were normal responses in pupillary light reflex, forced duction and convergence tests, but no ocular elevation in the vertical vestibulo-ocular reflex. The Bell's phenomenon was absent. She was diagnosed with moyamoya disease through brain MRI and cerebral angiography, and we found a hemorrhage in the right area of the midbrain. This hemorrhagic area was consistent with the right rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF). We think that the bilateral upgaze palsy was caused by damage to the riMLF in the affected side and to projections through the posterior commissure.

A Case of Bilateral Internuclear Ophthalmoplegia with No Brain Stem Lesion

PURPOSE: Bilateral internuclear ophthalmoplegia (INO) has been reported mostly in bilateral medial longitudinal fasciculus (MLF) lesion. To report a case who presented with typical bilateral internuclear ophthalmoplegia (INO) with no brainstem lesion on brain MRI. METHODS: Case presentation. RESULTS: Seventy two year-old woman presented with bilateral marked adduction limitation and diplopia. Bilateral marked adduction limitation did not cross midline. Nystagmus occured in abducting eye. Elevation and depression were normal in duction. Transcranial doppler revealed moderated stenosis of right internal carotid artery and severe stenosis of left intracranial internal carotid artery. Brain MRI revealed focal old infarction of right corona radiata and circumscribed acute infarction at more upper level of corona radiata, however, no pathologic finding was identified in brainstem. Initial severe exotropia was improved to 30 PD exotropia in primary position. Adduction limitation was markedly improved 2 months later but bilateral horizontal nystagmus in abducting eye persisted

A Case of Bilateral Internuclear Ophthalmoplegia

Internuclear ophthalmoplegia(INO) is a disorder of medial longitudinal fasciculus(MLF) that interconnects the ocular motor nuclei in the pons and midbrain. An intact MLF is essential for the production of all conjugate eye movements and an injury to the MLF results in ipsilateral adduction limitation and characteristic dissociated nystagmus of contralateral abducting eye. We experienced one case of bilateral internuclear ophthalmoplegia in a 70 years old ma, who had multiple lacunar infarctions in preaquductal gray matter, brain stem and basal ganglia.

A Case of Bilateral Internuclear Ophthalmoplegia

Internuclear ophthalmoplegia(INO)is a horiwntal ocular motor disturbance caused by a lesion of the medial longitudinal fasciculus. We have experienced a case of bilateral internuclear ophthalmoplegia associated with exotropia, which revealed the symptom of bilateral impairment of adduction and dissociated nystagmus of the abducting eye on horizontal gaze in either direction. No bilateral internuclear ophthalmoplegia caused by trauma has yet been reported in this country. Here we report the case of the trauma-related medial longitudinal fasciculus lesion and its pathophysiology along with a literatural review.