Eight Syndrome: Horizontal Gaze Palsy Plus Ipsilateral Seventh Nerve Palsy

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.

Horizontal Gaze Palsy and Ipsilateral Facial Nerve Palsy in Older Patient as Initial Manifestation of Very Late-Onset Multiple Sclerosis Successfully Treated with Oral Corticosteroids: A Case Report

Introduction

Multiple sclerosis (MS) is a demyelinating condition of the central nervous system (CNS) that primarily affects young adults. Very late-onset multiple sclerosis (VLOMS) is an uncommon form of MS, accounting for only 0.5 percent of all MS patients. Eye movement impairments such as internuclear ophthalmoplegia are common in MS, while horizontal gaze palsy is an uncommon occurrence.

Case Presentation

We report a case of a patient diagnosed with VLOMS who presented with left horizontal gaze palsy and ipsilateral facial nerve palsy. Brain magnetic resonance imaging showed Dawson's fingers in the left and right periventricular white matter; multiple small, round, hyperintense lesions in the left and right cortex and juxtacortical cerebellar hemisphere; and small hyperintense lesion in the left paramedian pontine reticular formation, suggesting the diagnosis of MS. Oral corticosteroids led to complete resolution of ocular movement and ipsilateral facial nerve palsy.

Conclusion

We propose that neuroimaging should be performed in ophthalmoplegia with a pattern representing CNS lesion and oral corticosteroids may be an effective alternative to high-cost intravenous corticosteroids.

Lower Motor Neuron Facial Palsy Due to Facial Colliculus Syndrome

In patients presenting to the Emergency Department (ED) with acute onset facial asymmetry, decision for disposition is usually based on whether it is an upper (UMN) or lower motor neuron (LMN) cranial nerve 7^th (CN7) palsy. In my institution, patients with UMN CN7 palsy would require admission for further investigations to look for central causes. Those who have an isolated LMN facial nerve palsy can be managed as outpatients.

A 36-year-old gentleman presented to the ED with acute vertigo and right facial weakness. He had no known cardiac risk factors. His vital signs on presentation were: Temperature 36.6℃, blood pressure 142/68mmHg, pulse rate 92/min, and oxygen saturation level (SpO2) 100% on room air. Initial neurological examination revealed a right LMN CN7 palsy without any other cranial nerve, cerebellar, or pyramidal deficits. He was given symptomatic treatment for vertigo without relief. Repeat examination subsequently showed a right conjugate gaze palsy with gaze-evoked nystagmus. There was no limb weakness or numbness. Gait was noted to be unsteady with a broad-based stance and truncal ataxia. Magnetic resonance imaging (MRI) of his brain subsequently showed an infarct affecting the right facial colliculus in the dorsal pons.

In my department, this was the first case of a young patient with a stroke presenting with LMN CN7 palsy. He was initially treated for a possible peripheral cause of his vertigo as he had a history of vestibular neuronitis, but without symptomatic improvement. Patients with neurological symptoms (e.g. vertigo) not resolving with initial treatment should prompt consideration for repeat neurological examination because the patient may have evolving neurological signs, as well as consider the potential for initial anchoring/cognitive bias. In this case, the gaze palsy and cerebellar signs were only noted on subsequent examination. Presence of LMN CN7 palsy with other associated neurological signs (including other cranial nerve palsies) would warrant further imaging to look for more sinister intracranial causes, including cerebral infarcts or space-occupying lesions. 

This case serves to remind medical practitioners to strongly consider a central cause (e.g. stroke) for patients presenting with an LMN facial palsy, even in young patients in the absence of other vascular risk factors, especially when other neurological symptoms and signs are present.

A Rare Neuro-Ophthalmological Condition in a Patient with Lung Adenocarcinoma: The Eight-and-a-Half Syndrome, Case Report and Review of the Literature

The eight-and-a-half syndrome is a rare neuro-ophthalmological condition caused by a structural lesion in the dorsal portion of the pons, involving critical areas of the brainstem, i.e., medial longitudinal fasciculus (MLF), abducens nucleus, facial genu, and colliculus. It is characterized by internuclear ophthalmoplegia with horizontal gaze palsy and peripheral facial palsy. Although the syndrome is most frequently caused by vascular or demyelinating diseases, several different underlying causes might occur. Herein, we describe a case of the eight-and-a-half syndrome caused by a lung adenocarcinoma metastasis localized in the lower pontine tegmentum. Then, we review the current literature on the underlying causes of the eight-and-a-half syndrome.

Bilateral facial colliculus syndrome caused by pontine tegmentum infarction: a case report

Background

Bilateral facial colliculus syndrome is a rare clinical presentation in patient with pontine infarction. We herein described a case of bilateral facial paralysis and complete horizontal gaze palsy possibly caused by paradoxical embolization from patent foramen ovale related stroke.

Case presentation

A 55-year-old male presented with sudden onset of complete peripheral facial palsy and horizontal gaze palsy after Valsava maneuver. MRI revealed symmetric involvement of bilateral pontine tegmentum in accordance with the location of facial colliculus. CSF analysis and follow-up MRI showed no evidence of central demyelinating disease. Subsequent echocardiography revealed patent foramen ovale and closure surgery was performed.

Conclusions

Facial colliculus syndrome with symmetric dorsal pontine tegmentum involvement may a rare manifestation in posterior circulation stroke.