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Título

Vertical and horizontal one and a half syndrome: a curious stroke presentation.

RESUMO

Presentation:
A 69-year-old female patient with a history of hypertension and heart failure was admitted with a sudden onset of right hemiparesis, dysarthria, and diplopia. On neurological examination, she had right hemiparesis, sparing the face, dysarthria, appendicular ataxia of the four limbs, cutaneous-plantar reflex in extension on the right, moderate bilateral ptosis more prominent on the left. Ocular movements examination demonstrated bilateral upgaze palsy with limitation of infraduction on the left, indicating vertical one and a half syndrome. For horizontal ocular movements, only the right eye could abduct. Also, there was bilateral conjugated leftward palsy, indicating horizontal one and a half syndrome. Doll’s eye test (oculocephalic reflex) was absent and the eyes were unable to converge.
Brain MRI showed hypersignal in the midbrain and pons to the left on T2-FLAIR, with water diffusion restriction, indicating a recent ischemic event. A small right cerebellar lesion with hypersignal in T2-FLAIR and water diffusion restriction was also present.

Discussion:
The one-and-a-half horizontal syndrome is a well-known and well-described clinical entity, characterized by complete limitation of ipsilateral horizontal eye movement and limitation of adduction of the contralateral eye. It occurs due to injury to the pontine paramedian reticular formation or the sixth cranial nerve nucleus and the ipsilateral medial longitudinal fasciculus. The vertical one-and-a-half syndrome is a less frequent entity, characterized by complete limitation of vertical eye movement in one eye and limitation of upward or downward vertical movement in the contralateral eye. Among its causes, the most common are related to injury to supranuclear structures, such as thalamic nuclei. However, other structures related to the control of the vertical gaze may be involved, such as reticular formation and pretectal area in the rostral midbrain, and rostral interstitial nucleus of the medial longitudinal fasciculus, and interstitial nucleus of Cajal.
The most frequent etiology related to both syndromes is cerebrovascular disease, followed by demyelinating diseases and encephalitis.

Final comments:
The association between the horizontal and vertical one and a half syndromes is rarely described in the literature. In addition to changes in ocular movement, our patient also had other neurological findings that are justified by the topography of the ischaemic lesions.

Palavras Chave

one-and-a-half syndrome; stroke; ischemic stroke;