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LETTER TO EDITOR
Year : 2009  |  Volume : 57  |  Issue : 4  |  Page : 499-501

Midbrain infarct presenting as isolated medial rectus palsy


Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India

Date of Acceptance26-Feb-2009
Date of Web Publication10-Sep-2009

Correspondence Address:
Vivek Lal
Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.55579

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How to cite this article:
Bal S, Lal V, Khurana D, Prabhakar S. Midbrain infarct presenting as isolated medial rectus palsy. Neurol India 2009;57:499-501

How to cite this URL:
Bal S, Lal V, Khurana D, Prabhakar S. Midbrain infarct presenting as isolated medial rectus palsy. Neurol India [serial online] 2009 [cited 2019 Dec 15];57:499-501. Available from: http://www.neurologyindia.com/text.asp?2009/57/4/499/55579


Sir,

A 30-year-old man, labourer by occupation, presented with sudden onset of giddiness followed by diplopia with horizontal separation of images on looking to extreme left gaze. On examination, hemodynamics were normal and neurological examination showed right medial rectus palsy [Figure 1]. Magnetic resonance imaging (MRI) of the brain showed a hyperintensity in rostral midbrain in diffusion weighted images [Figure 2] and flair images. He was thoroughly investigated for the causes of young stroke and was found to have dyslipidemia, which was treated with cholesterol-lowering agents and antiplatelets. The patient received visual tracking eye exercises during his hospital stay and his complaints resolved within three weeks.

Oculomotor nerve has two motor nuclei, the main motor nucleus and the accessory parasymphathetic nucleus. The main oculomotor nucleus which is situated in the anterior part of the gray matter surrounding the cerebral acqueduct of the midbrain at the level of superior colliculus supplies all the extrinsic muscles of the eye except the superior oblique and lateral rectus muscle. It consists of one unpaired central caudal nucleus for bilateral levator palpebrae superioris and four paired subnuclei. [1] The subnucleus for superior rectus muscle is situated dorsomedially and decussation of the fibers to the superior rectus takes place within the oculomotor nuclear complex; thus, lesions affecting the nucleus may simultaneously involve ipsilater al superior rectus subnuclei as well as crossing fibers resulting in bilateral superior rectus muscle palsy. [2] Ventral to the superior rectus subnuclei lies the subnuclei for ipsilateral inferior rectus followed by intermediate subnuclei for ipsilateral inferior oblique and the most ventrally situated subnuclei is for ipsilateral medial rectus [Figure 3]. Third nerve nuclear lesions cause weakness of bilateral superior rectus muscle ipsilateral inferior oblique, inferior rectus, medial rectus, with bilateral partial ptosis (due to involvement of central caudal subnuclei supplying both levator palpebrae superioris). This is a case of nuclear oculomotor nerve palsy with an unusual presentation due to strategic location of infarct in the rostral midbrain involving the medial rectus subnuclei which is situated most ventrally and can be diagnosed with diffusion weighted imaging (DWI). [3] Unilateral ocular palsy is commonly seen with lesions in the orbit or from muscular diseases and rarely from a third nerve nuclear lesion, though inferior oblique muscle palsy caused by involvement of intermediate subnuclei [4] and isolated inferior rectus palsy due to ipsilateral involvement of dorsally situated subnuclei or fascicular lesions have been described. [5] With use of DWI and other multimodality MRI the probability of picking up midbrain infarcts causing isolated oculomotor palsies have increased.

 
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1.Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 3 rd ed. Boston, MA: Little, Brown and Company; 1996.  Back to cited text no. 1    
2.Rabadi MH, Beltmann MA. Midbrain infarction presenting isolated medial rectus nuclear palsy. Am J Med 2005;118:836-7.  Back to cited text no. 2    
3.Kwon JH, Kwon SU, Ahn HS, Sung KB, Kim JS. Isolated superior rectus palsy due to contralateral midbrain infarction. Arch Neurol 2003;60:1633-5.  Back to cited text no. 3    
4.Castro O, Johnson LN, Mamourian AC. Isolated inferior oblique paresis from brain-stem infarction. Perspective on oculomotor fascicular organization in the ventral midbrain tegmentum. Arch Neurol 1990;47:235-7.  Back to cited text no. 4    
5.Lee DK, Kim JS. Isolated inferior rectus palsy due to midbrain infarction detected by diffusion- weighted MRI. Neurology 2006;66:1956-7.  Back to cited text no. 5    


    Figures

  [Figure 1], [Figure 2], [Figure 3]

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