Journal of Neuro-Ophthalmology, June 1982, Volume 2, Issue 2

Pontine hemorrhage causing Fisher one-and-a-half syndrome with facial paralysis.

The case of a 58-year-old white man with a history of high blood pressure and chronic obstructive pulmonary disease who developed double vision followed by right-sided facial paralysis is reported. A computerized axial tomogram (CT) scan showed an enhancing lesion in the pontine tegmentum, and the diagnoses of pontine glioma or hemorrhage were considered. Physical findings were limited to the cranial nerves. Conservative management with Decadron for 3 weeks resulted in a prompt clinical improvement, and a CT scan 1 month later showed resolution of the lesion, effectively ruling out a glioma. Total clinical recovery occurred at the end of 6 months. To our knowledge this is the first report of a case of Fisher one-and-a-half syndrome with facial paralysis correlated with computed tomography.

j. Clin. Neuro-ophth.l/n1l1/. 2: 12°-1.32, 1<)1\2. Pontine Hemorrhage Causing Fisher One-and-a-Half Syndrome with Facial Paralysis* KALARICKAL J. OOMMEN, M.D. MICHAEL 5. SMITH, M.D. ENRIQUE L. LABADIE, M.D. Abstract The case of a S8-year-old white man with a history of high blood pressure and chronic obstructive pulmonary disease who developed double vision followed by right-sided facial paralysis is reported. A computerized axial tomogram (CT) scan showed an enhancing lesion in the pontine tegmentum, and the diagnoses of pontine glioma or hemorrhage were considered. Physical findings were limited to the cranial nerves. Conservative management with Decadron@t for 3 weeks resulted in a prompt clinical improvement, and a CT scan 1 month later showed resolution of the lesion, effectively ruling out a glioma. Total clinical recovery occurred at the end of 6 months. To our knowledge this is the first report of a case of Fisher one-and-a-half syndrome with facial paralysis correlated with computed tomography. Case Report A 58-year-old hypertensive man had the sudden onset of double vision in July 1979. He had no headache, nausea, vomiting, tingling, numbness, or weakness of the extremities. He did not seek med­ical help until 3 weeks later when he had sudden onset of right-sided facial paralysis without other symptoms. On examination, the p<ltient's vit'll signs were entirely normal, general physical ex­amination was noncontributory, and he W<lS <llert and oriented. The patient had a right gaze p<llsy and a right internuclear ophthalmoplegia, but ver-from the Dt>partment of Neurul"lty. Vd"r"n' Adm,n"lr"!,,,n Medical Center (ELL). and the Arizond H,·"lth S< len< e' ( "nll'r (KID. MSS. ELL), Tucson. Aroz"nd. Clinical Assistant IV (KID). Neurull'~lCdl A"o I.ltl' (M~~). "nd Assistant Proft>ssor of Neurology (ELLI. Arozl.n., Hl·.,lth ~ i­ences Center; Chief of Neurology (ELL). Veter"n, Admini,tr.• ­tion Medical Center. • Prt>sented at tht> Nt>uru-uphthdlmnloItY C,.nft·rence "f thl' University of Miami School of Ml'dicinl' Mi.,mi. f1llridd, De­cember 1980. t Dexamethasone June 1982 tical eye movements were normal (Figs. 1A -I E). Pupils were 3 mm in ize, equal, reacted to light­< lccommodation, and both fundi were normal. There W<lS <l right peripheral facial paralysis, and par<llysis of the left vocal cord as well as the left side of the tongue. A AT scan showed <l small area of increased density in the pontine tegmentum close to the midline on the right side which enhanced with contrast (Figs. 3 A and 3 B). This provided CT correlation for the diagnosis of Fisher one-afld-<l­half syndrome. A diagnosis of hemorrhagic infarc­tion was made even though a pontine glioma could not entirely be ruled out. The patient was treated with Decadron@ for 3 weeks. During this time, the vocal cord and tongue pU<llysis resolved com­pletely. A week later, th., right facial paralysis and right internuclear ophthalmoplegia resolved, with persistence to <l lesser degree of right gaze palsy. Further resolution of the pontine lesion was dem­onstrated by a third CT scan (Fig. 3 C), effectively ruling out a glioma. Six months later, when the patient was seen again, the right g<lze paresis had resolved completely (Figs. 4 A -4 E). Discussion The "cuillmlltllr findings described here of .1 conjugate gJze p.llsy in (lnr direction .lnd intrrnu­c1eJr ophthJlmoplegi.l in the (lther direction may be produced by " lesion involving the ipsiLtt­er" l-horizont.ll conjugJte g.lze center .1Od the .ld­jacrnt medi.ll longitudin.ll E.1sciculu llf the sixth nerve nllr!eus, thr .ldj.lcent intenwunms..1Od the mediJI longitudin.ll f.lscicllilis (Fig. 2). Fisher c.llled such .1 constl·II.11ion of findings the "onr-dnd-.l-h.llf syndrllme."'·:< Tht' right- ided f.l­ci. ll pu.llysi W.1S dur to involvement of the inter­nJI genu of thr f.lei.ll n('rve. which in that region pJsses around the si th nerve nucleus. The vocal cord Jnd the twelfth nerve p.nalysis on the left side C<ln be explained only by postulating a second lesion involving the v"gal portion of the nucleus ambiguous <lnd the nearby hypoglossal nucleus 129 Figures IA -I L I II I [yes In pnmd'Y position (B I RIght gdze pJrJly<o< (>n Jllempwd "Kht gdze (CI R,ght Internuclear ,'phthdlmoplfKIJ on lefl l:Jze I':ole the rlght hypertropoc skew ( U I l'\urmJI upwJrd gdze (E I :'\ormJI downwdrd gue ,~ RIght ,-.., left ( b 1\ rQ~ ~ Ventricle _ \-...-l ~ucleus ot VI " .'r-.. PPRF ( '~::.:":;~:. \' ..~_\... "" i RootF,bersotvll I.' ' "-~"_\_ r "T • RoolF.Cl!rsotVI ~. ':. '. ~ '-'-' ~l--"" TraP€IOld BOdy /-'\' ". ~~:r- ~ Cort,cOSpinal FIbers Medial Longitudinal FascKulus G Bdsllar Artery Right Pontine Lesion Needed to Cause the One·and-a-Half Syndrome f i~ut\· 2. I)1.,gr.lI11 .. 11\'\\,111).:. 1\.....",,, n·.. p\'n~I~I4: h'lr Flsh{'r one--dnd-d-naJf '\11\1 ...111\' Journal of Clinical Neuro-ophlhalmology Figur.s3A -3C. rA) CT ,Cdn ,mdg~ dllh~ ponl,n('ll'v~1 ,huwln~ d ht"morrh~gl( In(,arctton. whlt(" .lrrow. 18) S.Jme .)~ A shuwing t.>nh;Jncement \Vftn cnntrd... t tofu lOn, bid ~ drrl'W fe) R("~uht. lion of the I('siun on H'pCdl CAT ~C".In .I month l~ltl·r. (Tapia's syndrome)." on the opposite side in the' lower medulla. Such multiple lesions in the br.lin stem are not unusual with arteriosclerotic-hyper­tensive disease of the vertebrobasilar system. The first report of a case of conjugate gaze palsy due to a pontine lesion with pathologic.l1 corn~I<1­tion was made by Bennett and Savill in 1888." The syndrome was described in detail later by Holm('s and Bielchowsky.r•.7In 1906, Wilson fir t des ribed a case of what we now call internudeM ophth.:sl- June 1982 Fi~ure~ -&A-4£. I\~L :o-h,nvtn~ tull r.m~l· l\t ,"',' l1hl\'''''ll\\''IlI'' c.~ mlmth... IJtC'r. m,'pl('~i.l ..md l'Hrrmitte' first lIs('d the tt>rm "ophth.llm(}pk~i.1 int('rnllcl".Jris" III 1\J22./O- 1l The combin.lti,.., ,.f th(' tw,' nlnditions inte••1 sin~le synd,,'mC' W.IS dC's.:ribed by . Miller FishN in I Q 07. Our C.IS(' t.lkes the ('ntity.1 step further with the .:sdditi,lO "f .1 peripher.ll f.lei.:sl pM.:slysis. AnothC'r interl'sting fe.:sture of this case is the f,Kt th.:st "nonf.lt.ll pontinl' hemorrhages" verified by CT SC.IO h.:svE' only recently bE'E'n reported by K.lse, M,lUlsby, dnd Mohr in 1980'" Our case, like 131 Fislwr l )ne-,lI1d-,l-H,llf these two prt'vious on<.>s, WJS tr<.>.lt<.>d with st<.>roids rrnpiricJlly but b,lsed upon our ('xp<.>ri('nct' with eln exp<.>rin1<.'ntJI h<.>rn.ltom.l .mimJI model published cls<'whrrc.I'I. II All thrN' CJsrs so tr<'Jt<.>d h.:ld d good r<'cov<.>ry. Summary A C.1St' of the Fisher one-clnd-.l-hellf syndrome with fdciJI pJf.llysis is reported. Internucle(lf llphth.llmopl<.>gi.l h.ld long been obs<.>rved by neu­rologi. ts, but the recognition of the syndromt' was m.lde only in the ecldy 20th century. C. Miller Fisher described the clssocicltion of conjugdte gclze p.llsy dnd intefllucle,H ophthcllmoplegia. This caSe with CT SCeln correlJtion ddds to the syndrome eln intra-clxi,ll pt'ripher,11 seventh nerve pclfellysis. It also t.Ikes exception to Nit>[st'n's rule, I:. which st.ltes that "pontine lesions cause permelnent con­tugelte eye deviations while hemispheric lesions Celuse only transient paresis." In elddition, the c1in­icell experience on this case elnd thelt of two others recently reported, indiceltes that for pontine hem­orrhelges, steroid prepelrcltions seem to be thera­peuticellly useful. References l. Fisher. C.M.: Some neuro-ophthalmologicaJ obser­vations. ]. Neurol. Neurosurg. Psychiiltry 30: 383-392, 1967. 2. Correliltive Neuroilncltomy clnd Functionill Neurol­ogy (15th ed.). Joseph C. Chusid, Ed. lange Medical Publiciltions, 1973, p. 32, Figure 1.33, 3. Shilrpe, J.A., Rosenberg, MA., Hoyt, W,F., Daroff, R.B., et .11.: Parillyti pontine exotropia. A sign of acute unilateral pontine gaze palsy and internuclear ophthalmoplegia. Neurology 24: 1076-1081. 1°74, 4. Bennett, A.H.. and Savill, T.: A case of permanent conjugate deviation of the eyes and head, the result of a lesion limited to the sixth nucleus; With remarks on associated lateral movements of the eyeballs, and rotation of the head and neck. Brilin 12: 102-116, 1889, 5. Holmes, G.: Palsies of the conjugate ocular move­ments. Br.]. Ophthalmol. 5: 141-149, 1921. o. Holmes, G.: The cerebral integration of ocular move­ments. Br. Med. ]. 2: 107-112, 1938. 7. Bu:~lchowsky, A.: lectures on motor abnormalities of l've'>. Arch Ophthdlmol. 13: 569-583, 1935. /I. r>uke-Elder, W.s.: Textbook of Ophthdlmology, V(,J. 4. Henry Kimptom, london, 1949, p. 4165, 9 I'JI n. l.: OculcJr p<llsies. Br. ]. Ophthillmol. 5: 250, /921. 10. Smith, J.L and Cogan, D.G.: Internuclear ophthal­moplegia. A review of 58 cases. A.M.A. Arch. Oph­thdlmol. 61: 687-694, 1959. II. Wd on, S.A.K.: Case No, 3, presented at the clinical meeting of the eurological Society of the United Kingdom, on March 29, 1906. Brain 27: 29B, 1906. 12. Kase, C.S.. Maulsby, G.O., and Mohr, J.P.: Partial pontine hematomas. Neurology 30: 652-655, 1980. 13. ldbadie. E.L <Ind Glover. D,: Physiopathogenesis of subdural hematomas. Part I: Histologicdl and bio­chemICal comp<lrisons of subcutaneous hematomas in rats with subdural hematomds in man. /. Neuro­surg. 45: 382-392, 1976. 14, Glover, D.. and ldbadie, E.l.: Physiopathogenesis of subdural hematomas, Part II: Inhibition of growth of experimental hematomas with dexamethasone. J. ,"eur05urg. 45: 393-397. 1976. IS, :-':eilsen, J.M.: A Textbook of Clinicill I\'eurology 13rd ed.). Paul B. Hoeber Inc .. :'-:e\'\l York, 1051. pp. 275. \Vrite {or reprints to: E. l. ldbadie. MD.. Neurology Service. Arizon.! HE'dlth Sciences Center. Tucson, Ari­z nJ ~572-t. , Jour.nal of Clinical Neuro-ophthalmology