Fascicular third nerve palsy with decreased vertical saccade velocity of the contralateral eye

Isolated or predominant ocular motor nerve palsy as a manifestation of brain stem stroke

BACKGROUND AND PURPOSE

There have been few reports of strokes producing isolated or predominant ocular motor nerve palsies as a clinical manifestation.

METHODS

We studied seven patients with brain stem stroke who had ocular motor palsies as the only or the predominant neurological manifestation, and we correlated their clinical features with radiological findings.

RESULTS

Five patients had small strokes in the area of oculomotor nuclei or fascicles and showed various combinations of oculomotor disturbances. Three of these patients showed vertical gaze paresis of the opposite eye. One patient with a small hemorrhage near the aqueduct of Sylvius showed fourth nerve palsy on the contralateral side, and a patient with a small infarct in the pontine tegmentum showed isolated sixth nerve palsy. Nonocular minor neurological signs included trigeminal sensory changes in four patients and clumsy arm in two. Ocular and nonocular dysfunctions generally improved within several months. Radiological findings of the brain stem correlated well with the ocular signs.

CONCLUSIONS

We conclude that acute brain stem stroke should be included in the differential diagnosis of isolated ocular motor nerve palsies and that appropriate diagnostic investigations should be performed in these cases.

Bilateral anterior cerebral artery territory infarction in the differential diagnosis of basilar artery occlusion

Two patients with bilateral anterior cerebral artery (ACA) territory infarction are presented whose initial diagnosis was basilar artery occlusion. Both had tetraparesis; in one it was asymmetrical. Both had their eyes open and did not respond to command except that after a delay they followed with their eyes a smoothly moving object; this was the only sign of awareness. One patient had a clear vertical gaze palsy in the upward and downward direction unaccompanied by pupillary abnormalities. Computed tomography revealed fresh bilateral ACA infarction in both patients; occlusion in the hind brain circulation was excluded by angiography in one. Both patients suffered from atrial fibrillation, so cardiac embolism was the most likely cause of the stroke. We conclude that bilateral ACA territory infarction should be considered in the differential diagnosis of basilar artery occlusion, even if accompanied by vertical gaze palsy.