Teaching Video NeuroImages: Thalamic infarct with pseudo-abducens and vertical gaze palsies and an unusual stroke mechanism
Citation Manager Formats
Make Comment
See Comments

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).
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
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
Disputes & Debates: Rapid online correspondence
NOTE: All authors' disclosures must be entered and current in our database before comments can be posted. Enter and update disclosures at http://submit.neurology.org. Exception: replies to comments concerning an article you originally authored do not require updated disclosures.
- Stay timely. Submit only on articles published within the last 8 weeks.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- 200 words maximum.
- 5 references maximum. Reference 1 must be the article on which you are commenting.
- 5 authors maximum. Exception: replies can include all original authors of the article.
- Submitted comments are subject to editing and editor review prior to posting.