Case of the week 25 (
January 2012
) Coexisting vertical and
horizontal one and a half syndromes
This 62 years
old man complains of sudden onset of diplopia since only
3 days . He is well controlled diabetic patient via oral
therapy 6 years ago ,no history of trauma , no past
history of any systemic illness .
Examination shows minimal cortical lens opacities ,
vision is 6/9 OD 6/9 OS , both
fundi are normal
What is your comment ... ??
See video for this patient
Supranuclear ocular movements comprise chiefly vertical
and horizontal movements; horizontal movements are
controlled by the subcortical centres located mainly at
the pontine level and vertical movements at the level of
the rostral midbrain.
An even more fundamental distinction is between vertical
and horizontal gaze palsies. The majority of gaze
palsies affect one direction in one plane of eye
movement only, reflecting the separation of the
supranuclear control systems for vertical and horizontal
eye movement.
The classic one and a half syndrome is produced by a
unilateral pontine tegmental lesion that includes the
paramedian pontine reticular formation and medial
longitudinal fasciculus on the same side, and has been
considered an important ocular sign in neurological
diagnosis.
Vertical, as distinct from horizontal, one and a half
syndrome, has also been documented recently
In the literatures there are only 3 reported cases
of coexisting vertical and
horizontal one and a half syndromes due to
infarcts in the right medial thalamus and the left upper
cerebellum
I report on a patient with concurrent vertical and
horizontal one and a half syndromes.
This is the only case I ve
encountered all my life , and I think it is the last
one.
Ocular movements of this patient showed :
1. For vertical movement, only the downward gaze
of the left eye is possible. Downward palsy of
the right eye and bilateral conjugated upward
palsy were seen.
2. For horizontal movements, the rightward gaze
of only the right eye is present. The rightward
palsy of the left eye and bilateral conjugated
leftward palsy are shown.
This
patient is identically the patient reported in 2000 by
the great Japanese neurosurgeon
S TERAO,
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