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Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 919--920

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

Shakya Bhattacharjee, Kher Lik Ng 
 Department of Neurology, Plymouth Hospital NHS Trust, Devon, UK

Correspondence Address:
Shakya Bhattacharjee
Flat 96, 21, Plymbridge Lane, Plymouth, PL68AX
UK




How to cite this article:
Bhattacharjee S, Ng KL. Vertical gaze palsy due to acute bilateral thalamic infarct without midbrain ischemia.Neurol India 2017;65:919-920


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 2020 Jan 18 ];65:919-920
Available from: http://www.neurologyindia.com/text.asp?2017/65/4/919/209506


Full Text



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}{Figure 2}{Figure 3}

[MULTIMEDIA:1]

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]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Khan M, Sidiropoulos C, Mitsias P. Unilateral thalamic infarction presenting as vertical gaze palsy: A case report. J Med Case Rep 2011;5:535.
2Aaron 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.
3Lazzaro 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.
4Clark JM, Albers GW. Vertical gaze palsies from medial thalamic infarctions without midbrain involvement. Stroke 1995;26:1467-70.