Abstract
Background
We present a unique case of a patient who suffered two rare events affecting the supranuclear control, first of the vertical and second of the horizontal eye movements. The first event involved bilateral thalamic infarcts that resulted in double depressor palsy. The second event occurred 1 year later and it involved supranuclear control of horizontal eye movements creating pursuit deficit.
Case presentation
A 47-year-old male presented with complaints of diplopia upon awakening. He had atrial fibrillation, mitral valve regurgitation, aortic valve regurgitation, and a history of spleen infarction 1 year ago. His right eye was hypertrophic and right eye downgaze was limited unilaterally of equal degree in adduction and abduction. The patient was diagnosed with double depressor palsy of the right eye. Magnetic resonance imaging (MRI) of the brain showed an old infarction of the left thalamus, and diffusion MRI showed acute infarction of the right thalamus. The patient’s daily warfarin dose was 2 mg and it was increased to 5 mg with cilostazol 75 mg twice a day. Seven weeks later, the patient’s ocular movement revealed near normal muscle action, and subjectively, the patient was diplopia free. At follow-up 12 months later, the patient revisited the hospital because of sudden onset of blurred vision on right gaze. He was observed to have smooth pursuit deficit to the right side, and orthophoric position of the eyes in primary gaze. MRI of the brain showed an acute infarction in the right medial superior temporal area.
Conclusions
The patient experienced very rare abnormal eyeball movements twice. This case highlights the importance of evaluating vertical movement of the eyes and vascular supplies when patients present with depressor deficit and supports the theory of a supranuclear function in patients who present with pursuit deficit.
Abbreviations
- MRI:
-
Magnetic resonance imaging
- MST:
-
Medial superior temporal area
- MDD:
-
Monocular depression deficiency
- riMLF:
-
Rostral interstitial nucleus of the medial longitudinal fasciculus
- VOR:
-
Vestibulo–ocular reflex
- OKN:
-
Optokinetic nystagmus
- IR:
-
Inferior rectus
- SR:
-
Superior rectus
- CT:
-
Computed tomography
- CN:
-
Cranial nerve
- INC:
-
Interstitial nucleus of Cajal
- AOP:
-
Artery of Percheron
- MT:
-
Medial temporal visual area
- DLPN:
-
Dorsolateral pontine nuclei
- NRTP:
-
Nucleus reticularis tegmenti pontis
References
Rosenbaum AL, Santiago AP (1999) Clinical strabismus management: principles and surgical techniques. W.B. Saunders, Philadelphia
Zee DS, Newman-Toker D (2005) Supranulcear and internuclear ocular motility disorders. In: Miller NR, Newman NJ, Biousse V, Kerrison JB (eds) Walsh & Hoyt’s clinical neuro-ophthalmology, vol 1, 6th edn. Lippincott Willians & Wilkins, Philadelphia, pp 907–967
Gentilini M, Renzi ED, Crisi G (1987) Bilateral thalamic paramedian artery infarcts: report of eight cases. J Neurol Neurosurg Psychiatry 50:900–909
Green JP, Newman NJ, Winterkorn JS (1993) Paralysis of downgaze in two patients with clinical-radiologic correlation. Arch Ophthalmol 111:219–222
Halmagyi GM, Evans WA, Hallinan JM (1978) Failure of downward gaze: the site and nature of the lesion. Arch Neurol 35:22–26
Jacobs L, Anderson PJ, Bender MB (1973) The lesions producing paralysis of downward but not upward gaze. Arch Neurol 28:319–323
Jacobs L, Heffner RR, Newman RP (1985) Selective paralysis of downward gaze caused by bilateral lesions of the mesencephalic periaqueductal gray matter. Neurology 35:516–521
Ozdemir N, Haciyakupoğlu S, Ersöz TR, Haciyakupoğlu G, Oğuz M (1995) Down gaze palsy due to periaqueductal lesion diagnosed by magnetic resonance imaging. Ophthalmologica 209:225–227
Walker MF, Kline LB (2007) Supranuclear and internuclear gaze pathways. In: Kline LB (ed) Neuro-ophgthalmology, 6th edn. Slack Incoporated, Thorofare, pp 45–74
Thurston SE, Leigh RJ, Crawford T, Thompson A, Kennard C (1988) Two distinct deficits of visual tracking caused by unilateral lesions of cerebral cortex in humans. Ann Neurol 23:266–273
Borchert MS (2005) Principles and techniques of the examination ocular motility and alignment. In: Miller NR, Newman JN, Biosse V, Kerrison JB (eds) Walsh and Hoyt’s clinical neuro-ophthalmology, vol 1, 6th edn. Lippincott Williams & Wilkins, Philadelphia, pp 887–905
Thurtell MJ (2014) Ophthalmoparesis, gaze conjugate lateral deficit and conjugate vertical deficit. In: Ettinger AB, Weisbrot DM (eds) Neurologic differential diagnosis. Cambridge University Press, Cambridge, pp 299–303
Park KA, Lee WT (1998) Medical neuroanatomy, 1st edn. Korea Medical Books Publisher, Seoul
Bae CS, Baek SY, Cho HJ (1993) Core text of neuroanatomy. Ko Moon Sa, Seoul
Kim JS, Hwang JM (2010) Clinical neuro-ophthalmology. E-public, Seoul
Lazzaro NA, Wright B, Castillo M, Fischbein NJ, Glastonbury CM, Hildenbrand PG, Wiggins RH, Quigley EP, Osborn AG (2010) Artery of Percheron infarction: imaging patterns and clinical spectrum. Am J Neuroradiol 31:1283–1289
Castaigne P, Lhermitte F, Buge A, Escourolle R, Hauw JJ, Lyon-Caen O (1981) Paramedian thalamic and midbrain infarcts: clinical and neuropathological study. Ann Neurol 10:127–148
Neto AR, Antunes ACM, Braga FM (1992) The posterior thalamoperforating artery (the main perforating trunk from P1) microsurgical study. J Bras Neurocir 3:103–107
George AE, Raybaud C, Salamon G, Kricheff II (1975) Anatomy of the thalamoperforating arteries with special emphasis on arteriography of the third ventricle: part 1. Am J Roentrenol Radium Ther Nucl Med 124:220–230
Saeki N, Rhoton AL Jr (1977) Microsurgical anatomy of the upper basilar artery and the posterior circle of Willis. J Neurosurg 46:563–578
Park SQ, Bae HG, Yoon SM, Shim JJ, Yun IG, Choi SK (2010) Morphological characteristics of the thalamoperforating arteries. J Korean Neurosurg Soc 47:36–41
Heubner (1872) Zur topographie der Ernährungsgabiete der einzelnen hirnarterien. Zbl Med Wiss 52:817–821. (Cited from George AE, Raybaud C, Salamon G, Kricheff II (1975) Anatomy of the thalamoperforating arteries with special emphasis on arteriography of the third ventricles: part I. Am J Roentgenol 124:220–230)
Duret M (1874) Recherches anatomiques sur la circulation de l’encéphale. Arch Phys Norm Path 1:60–91. (Cited from George AE, Raybaud C, Salamon G, Kricheff II (1975) Anatomy of the thalamoperforating arteries with special emphasis on arteriography of the third ventricles: part I. Am J Roentgenol 124:220–230)
Percheron G (1973) The anatomy of the arterial supply of the human thalamus and its use for the interpretation of the thalamic vascular pathology. Z Neurol 205:1–13
Shea YF, Lin OY, Chang RS, Luk JK (2012) Artery of Percheron infarction. Hong Kong Med J 18:446.e1–446.e2
Rodriguez EG, Lee JA (2013) Bilateral thalamic infarcts due to occlusion of the artery of Percheron and discussion of the differential diagnosis of bilateral thalamic lesions. J Radiol Case Rep 1(7):7–14
Pal S, Ferguson E, Madill SA, Al-Shahi Salman R (2009) Double depressor palsy caused by bilateral paramedian thalamic infarcts. J Neurol Neurosurg Psychiatry 80:1328–1329
Ozdemir N, Haciyakupoğlu S, Ersöz TR, Haciyakupoğlu G, Oğuz M (1995) Down gaze palsy due to periaqueductal lesion diagnosed by magnetic resonance imaging. Ophthalmologica 209:225–227
American Academy of Ophthalmology (2010) Basic and Clinical Science Course: Neuro-ophthalmology. American Academy of Ophthalmology, San Francisco, pp 197–214
Reid MS, DePoe SA, Darner RL, Reid JP, Slagle WS (2015) Clinical presentation of pseudo-abducens palsy. Optom Vis Sci 92:S76–S80
Thomke F, Hopf HC (2001) Abduction paresis with rostral pontine and/or mesencephalic lesions: pseudoabducens palsy and its relation to the so-called posterior internuclear ophthalmoplegia of Lutz. BMC Neurol 1:4
Wiest G, Mallek R, Baumgartner C (2000) Selective loss of vergence control secondary to bilateral paramedian thalamic infaction. Neurology 54:1997–1999
Authors’ contributions
KS is responsible for acquisition of the clinical information and writing up of the manuscript. YM is responsible for acquisition of the clinical information and reviewing the manuscript. LS is responsible for contributing to and reviewing the manuscript. All authors read and approved the final manuscript.
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The authors K.S., L.S., and Y.M. declare that they have no conflict of interest.
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Kim, S.J., Yeom, M.I. & Lee, S.U. A case of double depressor palsy followed by pursuit deficit due to sequential infarction in bilateral thalamus and right medial superior temporal area. Int Ophthalmol 37, 1353–1363 (2017). https://doi.org/10.1007/s10792-016-0407-0
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DOI: https://doi.org/10.1007/s10792-016-0407-0