945-2

Thalamic Infarct

Neuroimaging

Figure 1. Right medial thalamic infarct

Figure 2. Axial T2W images showing punctuate right and left cerebellar infarcts.

Figure 3. Midbrain

Figure 4. Right medial thalamic infarct

Figure 5. Left cerebellar infarct

Figure 6. Right cerebellar infarct

Somnolence

A 64-year old man suddenly developed loss of vision OU and somnolence

In the ER he was unresponsive with 8 mm sluggishly reactive pupils. He moved all four of his extremities but had bilateral decorticate posturing with bilateral upgoing toes.

Somnolence

A CT showed no abnormality. His condition improved on heparin and he began to respond to commands. He complained of headache, diplopia, dysphagia, vertigo, and nausea.

In the ICU BP 180/90, pulse 40-110 reg, grade II to IV systolic murmur.

OE

Somnolent responding to orders

Normal VA and confrontation fields

Pupils 3 mm. OU, reacting sluggishly to light (? Near)

EOM: full horizontal eye movements including convergence

A left UMN 7th nerve palsy

OE

Normal palatal movement with positive gageLeft hemiparesis with symmetrical hyperreflexia and bilateral upgoing toesOver the next 4 days his level of obtundation and weakness improved but his CNS status fluctuated markedly with his BP and was dependent on maintenance of a systolic BP > 180.

OE Day 13

Alert and oriented with normal speech

VA 20/25 OU, full fields

Pupils 4 mm OU, reacted briskly to light and near

EOM day 13

Eyes straight in primary gazeFull horizontal gaze, gaze evoked nystagmus OUFull upward gaze, no nystagmusParesis of downgaze i.e. saccades downPursuit downgaze almost fullVertical doll’s head intactConvergence absentIntact horizontal OKN, absent vertical OKN

References

Büttner U, Büttner-Ennever JA, Henn V. Vertical eye movement related unit activity in the rostral mesencephalic reticular formation of the alert monkey. Brain Res 1977;130:239-252.

Büttner-Ennever JA, Acheson JF, Büttner U, Graham EM, Leonard TJK, Sanders MD, Russell RR. Ptosis and supranuclear downgaze paralysis. Neurology 1989;39:385-389

Growdon JH, Winkler GF, Wray SH. Midbrain Ptosis. Arch Neurol 1974;30:179-181

Trojanowski JQ, Wray SH. Vertical gaze ophthalmoplegia: Selective paralysis of downgaze. Neurology 1980;30:605-610.

Trojanowski JQ, LaFontaine MH. Neuroanatomical correlates of selective downgaze paralysis. J Neuro Sci 1981;52:91-101.

http://library.med.utah.edu/NOVEL/Wray