Dados do Trabalho

Título

Vertical one-and-a-half syndrome in a patient with pecheron artery ischemia: A case report

RESUMO

Case Report
A 78-year-old female patient, presented at the hospital emergency with approximately 12 hours of sudden onset of diplopia, associated with dizziness. Neuro-ophthalmological examination showed no blinking alterations or ptosis. It also revealed torsional nystagmus associated with bilateral upgaze palsy with limitation of infraduction on the left. Pupillary reflexes were hypoactive bilaterally. No facial nerve paresis was observed. Previous pathological history consisted of type 2 diabetes mellitus and systemic arterial hypertension (SAH). Laboratory exams had no apparent abnormalities. The cardiac examination also had no evident alterations. Brain Computerized Tomography and Magnetic Resonance (MR) angiography were normal. Later magnetic resonance imaging (MRI) showed a restriction of the diffusion of water molecules in the thalamic regions and the mesencephalic tegment more evident in the right rostral region. The diagnosis was made with the combination of an ophthalmoparetic syndrome suggesting a midbrain impairment associated with the MRI results. Treatment protocol included dual platelet antiaggregation with acetylsalicylic acid and clopidogrel. Followed by clopido- grel for 21 days with statin association. At follow-up, partial recovery was achieved after 3 months in physical therapy.

Discussion
An ischemic stroke of the aPe can cause stupor, agitation, change in behavior, aphasia (dominant side), hemineglect (non-dominant side), and diplopia due to the involvement of the midbrain and interstitial nucleus of Cajal (INC), the largest nucleus of the medial longitudinal fasciculus (MLF). The INC is the neural integrator for vertical eye movement and is involved in vertical gaze, both with saccadic generation and the vestibulo-ocular reflex (VOR).

Two different types of VOHS have been described in the literature. The first: Consists of bilateral paralysis of the gaze upwards and monocular paresis of the gaze downwards with injury ipsilateral or contralateral. Paretic look down to the left and injury to the right. This variant has been described in thalamomesencephalic lesions, exactly like our patient. The second one: consists of difficulty to look down in association with monocular elevation paralysis, described in bilateral mesodiencephalic infarctions

Conclusion
This report describes a rare type of VOHS and brings a new insight on a possible aPe topography possibly causing this clinical presentation.

Palavras Chave

Pecheron artery, Vertical one and a half syndrome, Stroke, Cerebrovascular ischemia, Magnetic resonance imaging