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August 09, 2016; 87 (6) Resident and Fellow Section

Teaching Video NeuroImages: Thalamic infarct with pseudo-abducens and vertical gaze palsies and an unusual stroke mechanism

Shahin Khayambashi, Jonathan D. Fridhandler, Philip Teal, Jason J.S. Barton, Sharanpal K. Mann
First published August 8, 2016, DOI: https://doi.org/10.1212/WNL.0000000000002947
Shahin Khayambashi
From the Faculty of Medicine (S.K.) and Division of Neurology (J.D.F., P.T., J.J.S.B., S.K.M.), University of British Columbia, Vancouver, Canada.
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Jonathan D. Fridhandler
From the Faculty of Medicine (S.K.) and Division of Neurology (J.D.F., P.T., J.J.S.B., S.K.M.), University of British Columbia, Vancouver, Canada.
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Philip Teal
From the Faculty of Medicine (S.K.) and Division of Neurology (J.D.F., P.T., J.J.S.B., S.K.M.), University of British Columbia, Vancouver, Canada.
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Jason J.S. Barton
From the Faculty of Medicine (S.K.) and Division of Neurology (J.D.F., P.T., J.J.S.B., S.K.M.), University of British Columbia, Vancouver, Canada.
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Sharanpal K. Mann
From the Faculty of Medicine (S.K.) and Division of Neurology (J.D.F., P.T., J.J.S.B., S.K.M.), University of British Columbia, Vancouver, Canada.
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Teaching Video NeuroImages: Thalamic infarct with pseudo-abducens and vertical gaze palsies and an unusual stroke mechanism
Shahin Khayambashi, Jonathan D. Fridhandler, Philip Teal, Jason J.S. Barton, Sharanpal K. Mann
Neurology Aug 2016, 87 (6) e60; DOI: 10.1212/WNL.0000000000002947

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A 32-year-old man presented with confusion and diplopia. His examination showed complete vertical gaze palsy with relatively preserved vertical vestibulo-ocular reflexes, convergence nystagmus on attempted upgaze, alternating adducting hypertrophic skew deviation, limited right eye abduction with esotropia, and right limb ataxia (video on the Neurology® Web site at Neurology.org). MRI showed a left paramedian thalamic infarct (figure 1). Vertical gaze palsy results from damage to the rostral interstitial nucleus of the medial longitudinal fasciculus. The contralateral abduction limitation is consistent with pseudo-abducens palsy, attributed to disruption of descending mesencephalic inhibitory convergence pathways.1 Stroke mechanism was believed to be paradoxical embolus from a rare cardiovascular malformation (figure 2).

Figure 1
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Figure 1 MRI

Axial diffusion-weighted imaging sequence images show left paramedian thalamic infarct (A) with extension into the rostral medial midbrain (B). This location is suggestive of cardioembolic source in young adults presenting with thalamic infarcts.2

Figure 2
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Figure 2 CT reconstruction of partial anomalous pulmonary venous connection (PAPVC)

An abnormal vessel (white arrow) connects the portal vein to the pulmonary vein resulting in a porto-systemic shunt with confirmed bidirectional flow. Given the lack of vascular risk factors and negative hypercoagulable workup, stroke mechanism was most likely embolization of transient thrombus in the PAPVC vessel.

STUDY FUNDING

No targeted funding reported.

DISCLOSURE

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

Footnotes

  • ↵* These authors contributed equally to this work.

  • Download teaching slides: Neurology.org

  • Supplemental data at Neurology.org

  • © 2016 American Academy of Neurology

REFERENCES

  1. 1.↵
    1. Deleu D,
    2. Imam YZ,
    3. Mesraoua B,
    4. Salem KY
    . Vertical one-and-a-half syndrome with contralesional pseudo-abducens palsy in a patient with thalamomesencephalic stroke. J Neurol Sci 2012;312:180–183.
    OpenUrlPubMed
  2. 2.↵
    1. Pezzini A,
    2. Del Zotto E,
    3. Archetti S, et al.
    Thalamic infarcts in young adults: relastionship between clinical-topographic features and pathogenesis. Eur Neurol 2002;47:30–33.
    OpenUrlCrossRefPubMed
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Topics Discussed

  • All Cerebrovascular disease/Stroke
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