Case report of a patient with 'one-and-a-half plus syndrome: nine syndrome'

One-and-a-Half Syndrome in a Case of Brainstem Bleed

One-and-a-half syndrome (OHS) is a horizontal gaze palsy in one direction with internuclear ophthalmoplegia (INO) in the other. The only eye movement possible is the abduction of the contralateral eye with nystagmus. The usual structures affected are the medial longitudinal fasciculus and paramedian pontine reticular formation or the abducens nucleus. Most commonly, the OHS is caused by ischemia and demyelinating lesions. The other causes include infectious, neoplastic, and rarely traumatic. We report a case of a 42-year-old non-compliant hypertensive female who presented with giddiness, projectile vomiting, and right-sided hemiparesis and was found to have OHS on cranial nerve examination in the emergency department (ED). In the ED, the presence of complete horizontal gaze palsy in one direction with INO in the other direction should raise suspicion of a brainstem pathology.

Sixteen syndrome: a rare presentation of central demyelination

This case illustrates two diagnostic challenges for clinicians: the rarely described sixteen syndrome and the relationship between tumour necrosis factor (TNF)-alpha inhibitors and central demyelination. Sixteen syndrome affects horizontal eye movements and the facial nerve bilaterally reflecting a lesion in the posterior pontine tegmentum, adjacent to the fourth ventricle. Given its rarity and complexity of clinical signs, this syndrome risks misdiagnosis and mismanagement. The relationship between TNF-alpha inhibitors and demyelination is a complex issue in which causality is yet to be established. This diagnostic challenge poses a management dilemma for clinicians.

One-and-a-half Syndrome Associated with Multiple Sclerosis in a 14-year-old Girl

Purpose: To report the case of a 14-year-old female patient with one-and-a-half syndrome subsequently diagnosed with multiple sclerosis involving the pons.Case summary: A 14-year-old girl without any underlying disease presented with difficulty focusing and mild headache for 5 days. The patient showed conjugate gaze palsy to the left, limited adduction in the left eye, and abducting nystagmus in the right eye, which indicated one-and-half syndrome. T2 fluid-attenuated inversion recovery brain magnetic resonance imaging revealed multiple punctate hyperintensities in the pontine tegmentum, bilateral cerebral white matter, and cerebellum. Cerebrospinal fluid examination revealed oligoclonal bands and multiple sclerosis was diagnosed. The patient was treated with intravenous steroids and beta-interferon. Seven weeks later, limitation of eyeball movement and nystagmus had resolved completely.Conclusions: At the young age of 14 years, a patient presenting with one-and-a-half syndrome was diagnosed with multiple sclerosis. Children with multiple sclerosis may experience severe physical and cognitive impairments, and brainstem involvement predicts an especially poor prognosis. Early diagnosis and active treatment may help to prevent poor outcomes.