Diffusion-Weighted Imaging in Eight-and-a-Half Syndrome Presenting with Transient Hemiparesis
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Correspondence
Diffusion-Weighted Imaging in Eight-and-a-Half Syndrome Presenting with Transient Hemiparesis S. Uysal · A. Demirtas-Tatlidede · O. Y. Selcuk · V. Yayla
Received: 29 June 2012 / Accepted: 19 September 2012 / Published online: 12 October 2012 © Springer-Verlag Berlin Heidelberg 2012
Introduction
Case Report
One-and-a-half syndrome, defined as conjugate lateral gaze palsy in one direction and internuclear ophthalmoplegia (INO) in the other, is caused by a lesion comprising the medial longitudinal fasciculus (MLF) and paramedian pontine reticular formation (PPRF). The combination of one-and-a-half syndrome and accompanying facial nerve palsy was named as eight-and-a-half syndrome (one-anda-half and seven) by Eggenberger in 1998 with a lesion localized to lower pontine tegmentum [1]. The syndrome is rare and only a few cases have been reported in more than a decade. While the majority of cases with eight-and-a-half syndrome (EHS) reported to have cerebrovascular etiology, other described causes include infective mass lesions of the brainstem, vasculitis, and demyelination [1–4]. In this article, we present an unusual case of EHS that exhibited transient hemiparesis along with other clinical symptoms of EHS. We describe the patient’s demonstrative neuroophthalmological examination together with the neuroimaging counterparts, and discuss this rare finding in light of the available literature.
A 57-year-old man with typical vascular risk factors (hypertension, diabetes, smoking, and high alcohol consumption) was admitted to hospital due to double vision and left-sided weakness, presenting at neurological examination with EHS (Fig. 1) accompanied by mild left hemiparesis and positive left-sided Babinski reflex. Diffusion-weighted magnetic resonance imaging (MRI) revealed altered diffusion in the right inferior pontine tegmentum neighboring the fourth ventricle with marked ventral extension (Fig. 2a). Reduced diffusion suggestive of ischemia was further confirmed with corresponding low signal on the attenuated diffusion coefficient (ADC) map. Subsequent coronal T2-weighted image pinpointed a small lesion in the right paramedian pontine tegmentum (Fig. 2b). Further investigation of the intracranial and cervical vessels via magnetic resonance angiography (MRA) pointed to stenosis in the right vertebral artery accompanied by several intra- and extracranial stenotic segments.
Assoc. Prof. V. Yayla, M.D. () · S. Uysal, M.D. · A. Demirtas-Tatlidede, M.D. · O. Y. Selcuk, M.D. Department of Neurology, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, 34147 Istanbul, Turkey e-mail: [email protected]
Fig. 1 Eight-and-a-half syndrome. a Right-sided “complete” horizontal gaze palsy. b Left-sided “half” horizontal gaze palsy. Note the difference between the eyelids, pointing to lower motor neuron-type cranial nerve VII palsy on the right
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Fig. 2 Cranial magnetic resonance imaging. a Axial diffusion-weighted image shows a high-intensity lesion comprising the right inferior po
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