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We report a case of bilateral horizontal conjugate gaze palsy due to a dorsal median pontine haemorrhage. The development of horizontal gaze palsy has been attributed to lesions in the pontine tegmentum, and in this case, has occurred in conjunction with other features as part of Foville's syndrome. Complete horizontal gaze palsy is a rare clinical manifestation as bilateral involvement is unusual. Our case provides further insight into the intricacies of the brainstem neuroanatomy through a description of the involved neural pathways and nuclei accounting for complex neurological manifestations in one patient. [ABSTRACT FROM AUTHOR]

The medial longitudinal fasciculus is a key structure for conjugate horizontal eye movements by relaying signals from the abducens internuclear neurons to the medial rectus subdivision of the contralateral oculomotor nucleus. Thus, lesions involving the medial longitudinal fasciculus give rise to a typical neuro-ophthalmological sign, the internuclear ophthalmoplegia, which is characterized by impaired adduction of the ipsilesional eye and dissociated abducting nystagmus of the contralateral eye during attempted contralesional horizontal gaze. In addition, medial longitudinal fasciculus lesions may produce various other ocular motor abnormalities since the medial longitudinal fasciculus also conveys the signals for the control of the vestibulo-ocular reflex and smooth pursuit. Other possible ocular motor abnormalities include spontaneous vertical-torsional nystagmus, contraversive ocular tilt reaction, and impaired vestibulo-ocular reflex, especially for the contralesional posterior canal. Recognition of the ocular motor findings observed in the medial longitudinal fasciculus syndrome would aid in detection and localization of potentially grave lesions involving the brainstem. [ABSTRACT FROM AUTHOR]

Nine syndrome is a rare variant of one-and-a-half syndrome that results from a stroke in the posterior circulation, mainly manifesting as ipsilateral horizontal gaze palsy, facial palsy, and contralateral hemiataxia. Awareness of the clinical signs of this syndrome is crucial for accurate localization of the lesion and guiding further investigations. We report a case of nine syndrome presenting with signs of one-and-a-half syndrome, ipsilateral facial nerve palsy, hemiataxia, and hemiparesis. There are only a few cases of nine syndrome reported in the literature., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Al Salkhadi et al.)

The aim of this study is to investigate the trajectory of medial longitudinal fasciculus (MLF) and explore its anatomical relationship with the oculomotor nerve using tractography technique. The MLF and oculomotor nerve were reconstructed at the same time with preset three region of interests (ROIs): one set at the area of rostral midbrain, one placed on the MLF area at the upper pons, and one placed at the cisternal part of the oculomotor nerve. This mapping protocol was tested in an HCP‐1065 template, 35 health subjects from Massachusetts General Hospital (MGH), 20 healthy adults and 6 brainstem cavernous malformation (BCM) patients with generalized q‐sampling imaging (GQI)‐based tractography. Finally, the 200 μm brainstem template from Center for In Vivo Microscopy, Duke University (Duke CIVM), was used to validate the trajectory of reconstructed MLF. The MLF and oculomotor nerve were reconstructed in the HCP‐1065 template, 35 MGH health subjects, 20 healthy adults and 6 BCM patients. The MLF was in conjunction with the ipsilateral mesencephalic part of the oculomotor nerve. The displacement of MLF was identified in all BCM patients. Decreased QA, RDI and FA were found in the MLF of lesion side, indicating axonal loss and/or edema of displaced MLF. The reconstructed MLF in Duke CIVM brainstem 200 μm template corresponded well with histological anatomy. The MLF and oculomotor nerve were visualized accurately with our protocol using GQI‐based fiber tracking. This GQI‐based tractography is an important tool in the reconstruction and evaluation of MLF. [ABSTRACT FROM AUTHOR]

Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome has previously been reported in only 2 patients with progressive supranuclear palsy (PSP). Herein, we report a third case of WEBINO syndrome with PSP. The patient was an 81-year-old man who had experienced gradually increasing gait disturbance and occasional falls since the age of 78 years. At 80 years of age, he presented with cognitive impairment, parkinsonism, and oculomotor abnormalities. The oculomotor abnormalities consisted of vertical gaze palsy and loss of eye convergence. Brain magnetic resonance imaging demonstrated marked atrophy of the midbrain. He was diagnosed with PSP. At the age of 81 years, he presented with alternating extropia in his forward gaze and adduction paresis and outward nystagmus of the abducted eye in his horizontal gaze, both of which were compatible with WEBINO syndrome. Previously, we reported the first case of PSP with WEBINO syndrome, and another group recently reported a second case. In light of the previous cases and the present case, WEBINO syndrome in PSP should not be considered extremely rare. Furthermore, WEBINO syndrome has not been reported in other neurodegenerative disorders, which suggests that it might be a useful and specific diagnostic finding in PSP.

Internuclear ophthalmoplegia (INO), a neurological disorder is characterized by horizontal gaze palsy because of a lesion in the medial longitudinal fasciculus, a neural pathway that is mainly responsible for coordinating the movements of the eye. INO presents with diplopia and impaired adduction of the affected eye, accompanied by abducting eye nystagmus. The condition also arises from different etiologies which include multiple sclerosis, encephalitis, Lyme disease, HIV, and herpes zoster. Artery of Percheron (AOP) infarction is a subtype of bilateral thalamic infarction that poses a unique form of diagnostic perplexity due to its varied and often non-specific clinical manifestations such as altered responsiveness, memory disturbances, and oculomotor deficits. Here we discuss a 53-year-old female who presented with INO in the context of an AOP infarct. Under this context, the clinical finding includes some paradigms like nystagmus, anisocoria, and bilateral ptosis. Magnetic resonance imaging confirmed an acute infarct in the AOP territory, which supplies the rostral midbrain and paramedian thalami. This case emphasizes the critical importance of meticulous clinical evaluation and the utilization of advanced imaging techniques in diagnosing rare stroke syndromes like AOP infarction. Management of the patient included dual antiplatelet therapy to prevent further thromboembolic events and supportive care to address the immediate neurological deficits. Early recognition and prompt treatment are crucial for better patient outcomes. Long-term management focuses on the secondary prevention of stroke through lifestyle modifications, medical therapy, and regular monitoring. Education on uncommon stroke syndromes and continued research are essential for enhancing the accuracy of diagnosis and efficacy of treatment which ultimately leads to better patient care and prognosis., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jayakumar et al.)

This case underscores the importance of treating neurological deficits of an acute stroke presentation despite initial negative diffusion-weighted imaging (DWI), especially in the acute phase when there is high clinical suspicion of stroke. Additionally, it highlights the appropriate use of a WAKE-UP protocol for patients that present with stroke symptoms without a well-defined inception time. A 71-year-old female presented to the emergency department with symptoms of dizziness and double vision upon wake-up. While clinical exam findings revealed left intranuclear ophthalmoplegia (INO) and inability to ambulate due to gait ataxia, magnetic resonance imaging (MRI) was negative for acute stroke. Despite negative DWI MRI, this patient's clinical exam findings of a left INO and gait ataxia were indicative of an ischemic stroke localizing to the medial longitudinal fasciculus (MLF), and the patient received thrombolytics. Repeat MRI about 48 h later revealed an acute infarct in the left midbrain with a DWI lesion in the MLF., Competing Interests: We have no perceived conflict of interest to disclose., (Copyright 2024, Manjra et al.)

Internuclear ophthalmoplegia is a rare condition caused by injury to the medial longitudinal fasciculus inthe brainstem. It usually occurs in conditions such as stroke or multiple sclerosis and is extremely rareafter head injury. We report a case of unilateral internuclear ophthalmoplegia, which occurred after aminor head injury in a young male. His only symptoms were headache and diplopia. He was treatedconservatively, and his symptoms settled after 3 months. [West J Emerg Med. 2012;13(1):123–124.]

The medial longitudinal fasciculus (MLF) is a paired, highly specialized, and heavily myelinated nerve bundle responsible for extraocular muscle movements, including the oculomotor reflex, saccadic eye movements an smooth pursuit, and the vestibular ocular reflex. Clinically, lesions of the MLF are classically associated with internuclear ophthalmoplegia. However, clinical manifestations of a lesion in the MLF may be more complex and variable. We provide an overview of the neuroanatomy, neurologic manifestations, and correlative examples of the imaging findings on brain MRI of MLF lesions to provide the clinician and radiologist with a more comprehensive understanding of the MLF and potential clinical manifestations for an MLF lesion. [ABSTRACT FROM AUTHOR]

Background: Internuclear ophthalmoplegia (INO), characterized by impaired horizontal eye movement, occurred following an anterior cervical discectomy/fusions (ACDF). Case Description: A 48-year-old female with recurrent C5-6 foraminal stenosis presented with right C6 radiculopathy. She underwent a C5-6 ACDF, but postoperatively, complained of diplopia. Her examination revealed left-eye INO. Notably, the brain magnetic resonance imaging showed no significant radiological findings. The patient's diplopia and INO resolved spontaneously on postoperative day 2 and never recurred. Conclusion: Ocular complications following anterior cervical spine procedures are rare. Here, a 48-year-old female developed left eye INO following an ACDF that spontaneously resolved on postoperative day 2. [ABSTRACT FROM AUTHOR]

A 24-year-old female patient presented to the casualty following coconut fall on the head a few hours back with acute-onset binocular diplopia maximum on the left gaze and also on looking to the left and downward. Clinical examination revealed no external injuries, focal neurological deficits, or features of raised intracranial pressure. Computed tomography imaging was within normal limits. Hence, she was referred to ophthalmology by the neurosurgeon as a case of suspected partial third nerve palsy. Ocular examination revealed best-corrected visual acuity of 6/6 BE. There was limitation of adduction in the right eye and nystagmus in the left eye on attempted laevoversion. Convergence was absent. Anterior segment and fundus of both eyes were normal. Diplopia charting showed crossed diplopia which was maximum on left gaze. A clinical diagnosis of right anterior internuclear ophthalmoplegia (type-1) was made. It was confirmed by magnetic resonance imaging which revealed acute infarcts in the region of superior pons near right medial longitudinal fasciculus. The patient was treated with occlusion glasses.

Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome has previously been reported in only 2 patients with progressive supranuclear palsy (PSP). Herein, we report a third case of WEBINO syndrome with PSP. The patient was an 81-year-old man who had experienced gradually increasing gait disturbance and occasional falls since the age of 78 years. At 80 years of age, he presented with cognitive impairment, parkinsonism, and oculomotor abnormalities. The oculomotor abnormalities consisted of vertical gaze palsy and loss of eye convergence. Brain magnetic resonance imaging demonstrated marked atrophy of the midbrain. He was diagnosed with PSP. At the age of 81 years, he presented with alternating extropia in his forward gaze and adduction paresis and outward nystagmus of the abducted eye in his horizontal gaze, both of which were compatible with WEBINO syndrome. Previously, we reported the first case of PSP with WEBINO syndrome, and another group recently reported a second case. In light of the previous cases and the present case, WEBINO syndrome in PSP should not be considered extremely rare. Furthermore, WEBINO syndrome has not been reported in other neurodegenerative disorders, which suggests that it might be a useful and specific diagnostic finding in PSP. [ABSTRACT FROM AUTHOR]

BackgroundThe vertical vestibulo-ocular reflex (VOR) may be impaired in internuclear ophthalmoplegia (INO) as the medial longitudinal fasciculus (MLF) conveys VOR-signals from the vertical semicircular canals. It has been proposed that signals from the contralesional posterior semicircular canal (PSC) are exclusively transmitted through the MLF, while for the contralesional anterior canal other pathways exist.ObjectiveHere, we aimed to characterize dysfunction in individual canals in INO-patients using the video-head-impulse test (vHIT) and to test the hypothesis of dissociated vertical canal impairment in INO.MethodsVideo-head-impulse testing and magnetic resonance imaging were obtained in 21 consecutive patients with unilateral (n = 16) or bilateral (n = 5) INO and 42 controls. VOR-gains and compensatory catch-up saccades were analyzed and the overall function (normal vs. impaired) of each semicircular canal was rated.ResultsIn unilateral INO, largest VOR-gain reductions were noted in the contralesional PSC (0.55 ± 0.11 vs. 0.89 ± 0.08, p

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