Vertebrobasilar artery dissection manifesting as Millard-Gubler syndrome in a young ischemic stroke patient: A case report

Harnessing Neuroplasticity: A Case Report on Physiotherapy Rehabilitation for Millard-Gubler Syndrome

This case report glances at the physiotherapy management and motor recovery outcomes of a 47-year-old female who had a pontine infarction complicated by Millard-Gubler syndrome. Pontine infarction is a stroke that occurs in the pons region of the brainstem, resulting in impaired blood flow and subsequent tissue damage. Millard-Gubler syndrome, a rare form of pontine infarction, is distinguished by ipsilateral abducens (sixth cranial nerve) and facial (seventh cranial nerve) nerve palsy, which cause horizontal gaze palsy and facial weakness, respectively. Other common symptoms include contralateral hemiparesis or hemiplegia, dysarthria, and hypertonia. In this case, the patient had nystagmus, dysarthria, hypertonia, decreased consciousness, and limited mobility. Physiotherapy interventions were used in a multidisciplinary approach to address these deficits, with a focus on improving gaze stability, reducing hypertonia, facilitating bed mobility, and improving respiratory function. The outcomes were evaluated using standardised measures such as the Brunnstrom staging for motor recovery, the Modified Ashworth Scale for hypertonia, and the Functional Independence Measure for functional status. This case demonstrates the critical role of physiotherapy in improving motor recovery and functional outcomes.

Pontine Infarct Resulting in Millard-Gubler Syndrome: A Case Report

Millard-Gubler syndrome is a crossed brainstem syndrome involving the facial nerve, abducens nerve, and the pyramidal tracts, typically resulting in ipsilateral facial weakness and contralateral hemiparesis. Here we report the case of a 76-year-old female with no pertinent past medical history who presented to the emergency department with acute left-sided facial droop and right upper extremity sensory loss. A pontine infarction was identified on imaging and she was managed medically with complete recovery. Pontine infarction can result in Millard-Gubler syndrome and present with facial weakness and subtle contralateral limb symptoms.

Crossed brainstem syndrome revealing bleeding brainstem cavernous malformation: an illustrative case

BACKGROUND

Since the nineteenth century, a great variety of crossed brainstem syndromes (CBS) have been described in the medical literature. A CBS typically combines ipsilateral cranial nerves deficits to contralateral long tracts involvement such as hemiparesis or hemianesthesia. Classical CBS seem in fact not to be so clear-cut entities with up to 20% of patients showing different or unnamed combinations of crossed symptoms. In terms of etiologies, acute brainstem infarction predominates but CBS secondary to hemorrhage, neoplasm, abscess, and demyelination have been described. The aim of this study was to assess the proportion of CBS caused by a bleeding episode arising from a brainstem cavernous malformation (BCM) reported in the literature.

CASE PRESENTATION

We present the case of a typical Foville syndrome in a 65-year-old man that was caused by a pontine BCM with extralesional bleeding. Following the first bleeding episode, a conservative management was decided but the patient had eventually to be operated on soon after the second bleeding event.

DISCUSSION

A literature review was conducted focusing on the five most common CBS (Benedikt, Weber, Foville, Millard-Gubler, Wallenberg) on Medline database from inception to 2020. According to the literature, hemorrhagic BCM account for approximately 7 % of CBS. Microsurgical excision may be indicated after the second bleeding episode but needs to be carefully weighted up against the risks of the surgical procedure and openly discussed with the patient.

CONCLUSIONS

In the setting of a CBS, neuroimaging work-up may not infrequently reveal a BCM requiring complex multidisciplinary team management including neurosurgical advice.