Teaching Video NeuroImages: Thalamic infarct with pseudo-abducens and vertical gaze palsies and an unusual stroke mechanism

A 32-year-old man presented with confusion and diplopia. His examination showed complete vertical gaze palsy with relatively preserved vertical vestibulo-ocular reflexes, convergence nystagmus on attempted upgaze, alternating adducting hypertrophic skew deviation, limited right eye abduction with esotropia, and right limb ataxia (video on the Neurology® Web site at Neurology.org). MRI showed a left paramedian thalamic infarct (figure 1). Vertical gaze palsy results from damage to the rostral interstitial nucleus of the medial longitudinal fasciculus. The contralateral abduction limitation is consistent with pseudo-abducens palsy, attributed to disruption of descending mesencephalic inhibitory convergence pathways.1 Stroke mechanism was believed to be paradoxical embolus from a rare cardiovascular malformation (figure 2).

Source: Neurology - August 7, 2016 Category: Neurology Authors: Khayambashi, S., Fridhandler, J. D., Teal, P., Barton, J. J. S., Mann, S. K. Tags: Diplopia (double vision), All Cerebrovascular disease/Stroke, Embolism RESIDENT AND FELLOW SECTION Source Type: research