Stroke syndrome: A case of a Nine syndrome with a DWI-negative imaging

ABSTRACT

@#The brainstem contains important structures that give an array of clinical manifestations in pathologic processes. Here, we report a case of “Nine Syndrome” who was admitted in our institution with no acute findings on DWI sequence. The exact prevalence of Nine Syndrome has been accounted to only four cases reported in the literature and this is due to a pontine tegmentum lesion. Our patient is a 65 year-old male who presented with five-hour history of sudden onset of symptoms presented as ipsilateral gaze palsy, internuclear ophthalmoplegia, a lower motor neuron type of facial palsy, and a contralateral hemiparesis. Using a 1.5T MR cranial scanner and Philips scanner of the time-of-flight of the intracranial vessels, no evidence of acute territorial infarct but an old lacunar infarct was seen in the right pontine area. Both the anterior and posterior circulations are within normal course and caliber with no narrowing seen. Patient was started on dual anti-platelet, high dose statin, and anti-hypertensives on the fourth hospital day. Nine syndrome is a rare case, and its diagnosis rely on its clinical manifestations, neuroanatomy, and diagnostic imaging. An acute posterior ischemic infarct such as this may yield a negative DWI finding but should not impede the clinician in its early recognition and management.