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EIGHT AND A HALF SYNDROME: CASE REPORT

RESUMO

CASE PRESENTATION: Female patient, 52 years old, hypertensive, was admitted to the service with a complaint of blurred vision and difficulty closing her left eye suddenly 24 hours ago. She denied other symptoms or previous episodes. On examination, she had medial rectus muscle paresis in the right eye and lateral and medial rectus muscle paresis in the left eye, facial paralysis of a peripheral pattern on the left, without further changes. The following exams were performed: cranial tomography without alterations, skull magnetic resonance imaging (MRI) with recent lacunar ischemia in the left pons, normal cranial magnetic resonance angiography, neck magnetic resonance angiography with tapering and parietal irregularities in the distal portion of the foraminal segment (V2) of the left vertebral artery at the level of the axis tooth, without defining dissection areas to the method, normal echocardiogram, normal 24-hour Holter. Dual antiplatelet therapy, statin and blood pressure control were started. DISCUSSION: Eight-and-a-half syndrome (EHS) is rare, with few cases described in the world literature. Its early recognition is of great practical importance, as it has varied and potentially serious etiologies, with different therapeutic implications. It is characterized by conjugated horizontal gaze palsy, ipsilateral internuclear ophthalmoplegia, and peripheral facial palsy without impairment of taste, as taste fibers for the anterior 2/3 of the tongue travel through the intermediate nerve, which has its nucleus in the medulla. The syndrome occurs due to a lesion that affects the medial longitudinal fasciculus, the paramedian pontine reticular formation and the fasciculus of the facial nerve on the same side at the level of the pons. The diagnosis is easily missed as it needs a detailed eye movement examination. It is mainly caused by stroke, multiple sclerosis, gliomas, metastases and vascular malformations. Less frequent etiologies include iatrogenesis related to tumor resection, neurocysticercosis, systemic lupus erythematosus and myasthenia gravis if isolated ocular involvement. FINAL COMMENTS: The clinical recognition of EHS is essential for an accurate topographical diagnosis of pontine tegmentum lesions. Vascular disease and multiple sclerosis are the main differential diagnoses, although rarer causes should always be considered. MRI is the exam of choice for topographic and etiologic diagnosis. Treatment depends on the cause.

Palavras Chave

Ischemia. Paralysis. Diplopia