Thalamic Infarct

945-2Thalamic Infarct

Figure 2. Axial T2W images showing punctuate right and left cerebellarinfarcts.

Figure 3. Midbrain

Figure 4. Right medial thalamic infarct

Figure 5. Left cerebellar infarct

Figure 6. Right cerebellar infarct

SomnolenceA 64-year old man suddenly developedloss of vision OU and somnolenceIn the ER he was unresponsive with 8 mmsluggishly reactive pupils. He moved allfour of his extremities but had bilateraldecorticate posturing with bilateral upgoingtoes.

SomnolenceA CT showed no abnormality. Hiscondition improved on heparin and hebegan to respond to commands. Hecomplained of headache, diplopia,dysphagia, vertigo, and nausea.In the ICU BP 180/90, pulse 40-110 reg,grade II to IV systolic murmur.

OESomnolent responding to ordersNormal VA and confrontation fieldsPupils 3 mm. OU, reacting sluggishly tolight (? Near)EOM: full horizontal eye movementsincluding convergenceA left UMN 7 th nerve palsy

OENormal palatal movement with positivegageLeft hemiparesis with symmetricalhyperreflexia and bilateral upgoing toesOver the next 4 days his level ofobtundation and weakness improved buthis CNS status fluctuated markedly withhis BP and was dependent onmaintenance of a systolic BP > 180.

OE Day 13Alert and oriented with normal speechVA 20/25 OU, full fieldsPupils 4 mm OU, reacted briskly to lightand near

EOM day 13Eyes straight in primary gazeFull horizontal gaze, gaze evokednystagmus OUFull upward gaze, no nystagmusParesis of downgaze i.e. saccades downPursuit downgaze almost fullVertical doll’s head intactConvergence absentIntact horizontal OKN, absent vertical OKN

ReferencesBüttner U, Büttner-Ennever JA, Henn V.Vertical eye movement related unit activityin the rostral mesencephalic reticularformation of the alert monkey. Brain Res1977;130:239-252.Büttner-Ennever JA, Acheson JF, BüttnerU, Graham EM, Leonard TJK, SandersMD, Russell RR. Ptosis and supranucleardowngaze paralysis. Neurology1989;39:385-389

Growdon JH, Winkler GF, Wray SH.Midbrain Ptosis. Arch Neurol1974;30:179-181Trojanowski JQ, Wray SH. Vertical gazeophthalmoplegia: Selective paralysis ofdowngaze. Neurology 1980;30:605-610.Trojanowski JQ, LaFontaine MH.Neuroanatomical correlates of selectivedowngaze paralysis. J Neuro Sci1981;52:91-101.

http://library.med.utah.edu/NOVEL/Wray