Pontine_Infarction

The patient is a 62 year old right handed man, status post myocardial infarction in 1989 and on Coumadin. In 1993 he presented with a history of three separate TIAs 1.Instantaneous perioral tingling and/or numbness lasting less than 1 minute. 2.Episodic numbness of the right hand and foot lasting less than 2 minutes. 3.Double vision in central gaze and perhaps more to the left than the right, lasting for 1 week but progressively improving. On the morning of January 11th, he worked with his physical therapist and walked round the block. Shortly after he had difficulty with tandem gait and standing on one foot. Later the same day, his right hand and foot became numb and he had "tingling" paresthesia. His speech became dysarthric. He was admitted to the Massachusetts General Hospital. Past History: Migraine headache with visual aura Amblyopia since childhood Neurological examination: No carotid bruits Mild left hemiparesis. He veered to the left walking Mild left arm dysmetria on finger to nose Reflexes brisk throughout, 3+ without clonus Extensor plantar response on the left Sensory exam normal Neuro-ophthalmological examination: Amblyopic eye OS since childhood Visual acuity OD: 20/20, OS: 20/400 Pupils, fields and fundi normal. Ocular motility: Right internuclear ophthalmoplegia on gaze left with adduction weakness OD Right horizontal gaze paresis with gaze evoked nystagmus Full vertical gaze Poor convergence Transesophageal echocardiogram: Normal Posterior transcranial Doppler studies: Unremarkable Brain MRI: Sagittal T1 axial dual echo T2 WI were obtained pre and post gadolinium. A T2 bright signal was found in the right anterior pons (T1 dark) which did not enhance significantly with gadolinium. It extended to the posterior right pons and was consistent with infarction. In addition, punctate T2 hyperintense signal was present in the centrum semiovale and the forceps major and minor consistent with microangiopathic disease. Brain MRA showed an abrupt change in flow signal in the midbasilar artery compatible with a focal stenosis at that site and decreased flow velocity beyond that point consistent with significant stenosis. The focal stenosis of the basilar artery suggested a thrombo-embolic etiology for the right pontine infarct. Diagnosis: Basilar artery stenosis Right pontine infarct Treatment: Patient completed a ten day course of intravenous heparin and was restarted on Coumadin and discharged home improved. Prognosis for recovery of the one-and-a-half syndrome was excellent. On follow-up his eye movements returned to normal within six weeks and he had no diplopia. The patient developed glaucoma and was followed in the Neurovisual Unit until June 27, 2001 without any further TIAs. See also: http://content.lib.utah.edu/cdm/ref/collection/ehsl-shw/id/345