Teaching Video NeuroImages: Nine syndrome in inferior paramedian pontine infarction: More than meets the eye

A 54-year-old man with a medical history notable for diabetes mellitus and coronary artery bypass surgery presented to the emergency department with acute-onset vertigo, diplopia, hemiparesis, and hemihypesthesia of his left arm and leg. On cranial nerve examination, he displayed a 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, and peripheral right facial palsy (figure 1; video at Neurology.org). These features were consistent with an ischemic pontine lesion affecting the right (1) paramedian pontine reticular formation and medial longitudinal fasciculus (one-and-a-half syndrome), (2) facial nerve fascicle (seventh cranial nerve palsy), (3) corticospinal tract, and (4) medial lemniscus pathway (the latter 2 comprising the final "half syndrome") (figure 2), thereby constituting the so-called nine syndrome.1

Source: Neurology - August 21, 2017 Category: Neurology Authors: Maas, R. P. P. W. M., Verrips, A. Tags: DWI, All Neuro-ophthalmology, Ocular motility, Nystagmus, Infarction RESIDENT AND FELLOW SECTION Source Type: research