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Table of Contents    
NEUROIMAGES
Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 919-920

Vertical gaze palsy due to acute bilateral thalamic infarct without midbrain ischemia


Department of Neurology, Plymouth Hospital NHS Trust, Devon, UK

Date of Web Publication5-Jul-2017

Correspondence Address:
Shakya Bhattacharjee
Flat 96, 21, Plymbridge Lane, Plymouth, PL68AX
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_4_17

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How to cite this article:
Bhattacharjee S, Ng KL. Vertical gaze palsy due to acute bilateral thalamic infarct without midbrain ischemia. Neurol India 2017;65:919-20

How to cite this URL:
Bhattacharjee S, Ng KL. Vertical gaze palsy due to acute bilateral thalamic infarct without midbrain ischemia. Neurol India [serial online] 2017 [cited 2019 Aug 21];65:919-20. Available from: http://www.neurologyindia.com/text.asp?2017/65/4/919/209506




A 62-year old gentleman presented with acute-onset altered sensorium and diplopia on vertical gaze. Clinical examination revealed a pure vertical gaze palsy, which could be overcome by the oculocephalic manoeuvre; however, intact horizontal gaze persisted [video 1]. He had no other pyramidal, extrapyramidal, or cerebellar signs. Magnetic resonance imaging (MRI) of the brain with diffusion sequences showed acute bilateral paramedian thalamic infarcts but with no evidence of midbrain ischemia [Figure 1],[Figure 2],[Figure 3]. He was diagnosed with supranuclear gaze palsy caused by artery of Percheron infarct. The artery of Percheron is a rare solitary arterial trunk from the posterior cerebral circulation that supplies the paramedian thalami and the rostral midbrain bilaterally.
Figure 1: Magnetic resonance imaging (diffusion-weighted sequence) axial view showing high signals in both paramedian nuclei of thalamus (black arrows)

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Figure 2: Magnetic resonance imaging (apparent diffusion coefficient) axial view shows low signals in the corresponding thalamic areas suggestive of acute infarction (black arrows)

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{Figure 3}




Vertical gaze palsy is usually observed with lesions of the mesencephalic rostral interstitial nucleus, the interstitial nucleus of Cajal, the posterior commissure, and the peri-aqueductal gray matter.[1] Vertical gaze palsies caused by paramedian thalamic infarction without midbrain involvement are rare. A recent stroke study showed that, among 17 Percheron infarct cases, 53% had upgaze restriction, 29% had both upgaze and downgaze restriction, 12% had only downgaze restriction, and 18% had skew deviation.[2] Percheron infarct is a rare variety of thalamic infarct presenting with the classical triad of altered mental status, vertical gaze palsy, and memory impairment.[2],[3] The exact reason for the vertical gaze palsy in paramedian thalamic infarct is not clear. The most likely reason is the interruption of the supranuclear inputs when they pass through the medial thalamus en route to the pretectal and prerubral areas.[4]

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  References Top

1.
Khan M, Sidiropoulos C, Mitsias P. Unilateral thalamic infarction presenting as vertical gaze palsy: A case report. J Med Case Rep 2011;5:535.  Back to cited text no. 1
[PUBMED]    
2.
Aaron S, Mani S, Prabhakar AT, Karthik K, Patil AK, Babu PS, et al. Stuck with a drowsy patient, evoke the Percheron. Neurol India 2015;63:542-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Lazzaro NA, Wright B, Castillo M, Fischbein NJ, Glastonbury CM, Hildenbrand PG, et al. Artery of percheron infarction: Imaging patterns and clinical spectrum. AJNR Am J Neuroradiol 2010;31:1283-9.  Back to cited text no. 3
[PUBMED]    
4.
Clark JM, Albers GW. Vertical gaze palsies from medial thalamic infarctions without midbrain involvement. Stroke 1995;26:1467-70.  Back to cited text no. 4
[PUBMED]    


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