A 54-year-old man with acute-onset diplopia and weakness

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A 54-year-old man with acute-onset diplopia and weakness Teaching NeuroImages Neurology Resident and Fellow Section © 2017 American Academy of Neurology

Vignette Neurologic examination Medical history Diabetes mellitus Coronary artery bypass surgery Emergency department – acute onset symptoms Diplopia Vertigo Hemiparesis and hemihypesthesia of left arm and leg Neurologic examination Conjugate right horizontal gaze palsy Diminished right eye adduction Horizontal left-beating nystagmus on leftward gaze Paralytic pontine exotropia of the left eye Gaze-evoked vertical nystagmus Peripheral right facial palsy Maas and Verrips © 2017 American Academy of Neurology

Imaging I Maas and Verrips © 2017 American Academy of Neurology Video Part 1: Horizontal eye movements. Conjugate right horizontal gaze palsy, diminished right eye adduction, horizontal left-beating nystagmus on leftward gaze, and paralytic pontine exotropia of the left eye. The ipsilateral gaze paresis, internuclear ophthalmoplegia on contralateral gaze, and contralateral exotropia define the one-and-a-half syndrome. Part 2: Vertical eye movements. Gaze-evoked vertical nystagmus. Part 3: Facial nerve examination. Peripheral right facial palsy (seventh cranial nerve palsy). The hemiparesis and hemihypesthesia of the left arm and leg (not shown in this video) constitute the final ‘half syndrome’. Figure Conjugate right horizontal gaze palsy (shown here is attempted rightward gaze), paralytic pontine exotropia of the left eye, and peripheral right facial palsy Maas and Verrips © 2017 American Academy of Neurology

Imaging II Maas and Verrips © 2017 American Academy of Neurology Figure Diffusion restriction along the entire right paramedian aspect of the caudal pons (A) with a prominent hypointense signal on the corresponding ADC map (B), indicative of an ischemic lesion. Maas and Verrips © 2017 American Academy of Neurology

‘Nine syndrome’ in inferior paramedian pontine infarction Right paramedian reticular formation Medial longitudinal fasciculus 7th cranial nerve palsy Facial nerve fascicle ‘Half syndrome’ Corticospinal tract Medial lemniscus pathway Reference Rosini F, Pretegiani E, Guideri F, Cerase A, Rufa A. Eight and a half syndrome with hemiparesis and hemihypesthesia: the nine syndrome? J Stroke Cerebrovasc Dis. 2013;22:e637-638. Maas and Verrips © 2017 American Academy of Neurology

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