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March 14, 2023; 100 (11) Resident & Fellow Section

Teaching Video NeuroImage: Wernekink Commissure Syndrome

Takashi Nakamura, Tatsuya Ueno, Rie Haga, Akira Arai, Masayuki Baba, Masahiko Tomiyama
First published December 19, 2022, DOI: https://doi.org/10.1212/WNL.0000000000201706
Takashi Nakamura
From the Department of Neurology (T.N., T.U., R.H., A.A., M.B.), Aomori Prefectural Central Hospital; and Department of Neurology (M.T.), Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan.
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Tatsuya Ueno
From the Department of Neurology (T.N., T.U., R.H., A.A., M.B.), Aomori Prefectural Central Hospital; and Department of Neurology (M.T.), Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan.
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Rie Haga
From the Department of Neurology (T.N., T.U., R.H., A.A., M.B.), Aomori Prefectural Central Hospital; and Department of Neurology (M.T.), Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan.
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Akira Arai
From the Department of Neurology (T.N., T.U., R.H., A.A., M.B.), Aomori Prefectural Central Hospital; and Department of Neurology (M.T.), Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan.
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Masayuki Baba
From the Department of Neurology (T.N., T.U., R.H., A.A., M.B.), Aomori Prefectural Central Hospital; and Department of Neurology (M.T.), Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan.
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Masahiko Tomiyama
From the Department of Neurology (T.N., T.U., R.H., A.A., M.B.), Aomori Prefectural Central Hospital; and Department of Neurology (M.T.), Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan.
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Teaching Video NeuroImage: Wernekink Commissure Syndrome
Takashi Nakamura, Tatsuya Ueno, Rie Haga, Akira Arai, Masayuki Baba, Masahiko Tomiyama
Neurology Mar 2023, 100 (11) 540-541; DOI: 10.1212/WNL.0000000000201706

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A 62-year-old woman presented with sudden-onset staggering gait and dysarthria. Neurologic examination revealed truncal and appendicular ataxia in all limbs and cerebellar dysarthria (Video 1), slight slowing of internal right eye rotation during leftward gaze, and left eye nystagmus on abduction. The deep tendon reflexes were normal. Diffusion-weighted imaging showed a high-signal midline lesion in the right midbrain (Figure). We diagnosed the patient with Wernekink commissure syndrome caused by midbrain infarction. Wernekink commissure syndrome is a rare syndrome of bilateral ataxia and oculomotor dysfunction caused by caudal paramedian midbrain lesions.1,2 The responsible vessel is considered the inferior paramedian mesencephalic artery, which originates from both the distal basilar artery and proximal posterior cerebral artery or the superior cerebellar artery.2 This lesion involves the superior cerebellar peduncles, their decussation, and the medial longitudinal fasciculi.2 Clinicians should consider midbrain lesions in patients with acute-onset bilateral ataxia.

Video 1

Neurological examination showed cerebellar dysarthria, bilateral limb ataxia, and ataxic gait.Download Supplementary Video 1 via http://dx.doi.org/10.1212/201706_Video_1

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Figure Brain MRI

(A, B) Axial brain MRI showed hyperintensity and hypointensity in the right paramedian midbrain on diffusion-weighted imaging and apparent diffusion coefficient map, respectively. (C) Magnetic resonance angiography showed no obvious major artery stenosis on day 1. (D, E) Axial and coronal T2-weighted images on day 27 showed a faint high-signal lesion at the same site (arrow). The inferior olivary nucleus showed no signal change.

Study Funding

The authors report no targeted funding.

Disclosure

The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

Acknowledgment

The authors thank Edanz (jp.edanz.com/ac) for editing a draft of this manuscript.

Appendix Authors

Table

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Submitted and externally peer reviewed. The handling editor was Resident and Fellow Section Editor Whitley Aamodt, MD, MPH.

  • Teaching slides links.lww.com/WNL/C532.

  • Video links.lww.com/WNL/C533.

  • Received June 26, 2022.
  • Accepted in final form November 3, 2022.
  • © 2022 American Academy of Neurology

References

  1. 1.↵
    1. Dong M,
    2. Wang L,
    3. Teng W, et al.
    Wernekink commissure syndrome secondary to a rare 'V'-shaped pure midbrain infarction: a case report and review of the literature. Int J Neurosci. 2020;130(8), 826-833.
    OpenUrl
  2. 2.↵
    1. Zhou C,
    2. Xu Z,
    3. Huang B, et al.
    Caudal paramedian midbrain infarction: a clinical study of imaging, clinical features and stroke mechanisms. Acta Neurol Belg. 2021;121(2), 443-450.
    OpenUrl

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