945-2 Thalamic Infarct
Neuroimaging Figure 1. Right medial thalamic infarct
Figure 2. Axial T2W images showing punctuate right and left cerebellar infarcts.
Somnolence A 64-year old man suddenly developed loss of vision OU and somnolence In the ER he was unresponsive with 8 mm sluggishly reactive pupils. He moved all four of his extremities but had bilateral decorticate posturing with bilateral upgoing toes.
Somnolence A CT showed no abnormality. His condition improved on heparin and he began to respond to commands. He complained of headache, diplopia, dysphagia, vertigo, and nausea. In the ICU BP 180/90, pulse 40-110 reg, grade II to IV systolic murmur.
OE Somnolent responding to orders Normal VA and confrontation fields Pupils 3 mm. OU, reacting sluggishly to light (? Near) EOM: full horizontal eye movements including convergence A left UMN 7th nerve palsy
OE Normal palatal movement with positive gage Left hemiparesis with symmetrical hyperreflexia and bilateral upgoing toes Over the next 4 days his level of obtundation and weakness improved but his CNS status fluctuated markedly with his BP and was dependent on maintenance of a systolic BP > 180.
OE Day 13 Alert and oriented with normal speech VA 20/25 OU, full fields Pupils 4 mm OU, reacted briskly to light and near
EOM day 13 Eyes straight in primary gaze Full horizontal gaze, gaze evoked nystagmus OU Full upward gaze, no nystagmus Paresis of downgaze i.e. saccades down Pursuit downgaze almost full Vertical doll’s head intact Convergence absent Intact horizontal OKN, absent vertical OKN
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Growdon JH, Winkler GF, Wray SH. Midbrain Ptosis. Arch Neurol 1974;30:179-181 Trojanowski JQ, Wray SH. Vertical gaze ophthalmoplegia: Selective paralysis of downgaze. Neurology 1980;30:605-610. Trojanowski JQ, LaFontaine MH. Neuroanatomical correlates of selective downgaze paralysis. J Neuro Sci 1981;52:91-101.