Midbrain Hemorrhage

The patient is a 49 year old woman who was in good health until January 17, 1991. When, at work one morning, she had an acute attack of light headedness and double vision and collapsed on the floor without loss of consciousness. She developed a severe retro-orbital headache. She was taken to the local hospital and admitted. After five days she was transferred to the Massachusetts General Hospital (MGH) for cerebral angiography. Past History: Negative for hypertension or recent trauma. On no medications. Family History: Negative for CNS disease or bleeding dyscrasias On admission to the MGH, she had mild headache and vertical double vision. Blood pressure 120/80, pulse 84 regular. Neurological examination: Normal mental status Speech normal Cranial Nerves: Visual acuity 20/20 OU Pupils 5 mm OU reacting sluggishly to light and brisk to accommodation. Supranuclear paralysis of upgaze The remainder of the cranial nerves normal Motor System: Strength 5/5 bilaterally Reflexes: 2+ symmetrical with flexor plantar responses down. Sensory System: Normal. Co-ordination: No ataxia 1/22/91 Neuro-Ophthalmology Consult: Visual acuity J2 OU with reading glasses. Visual fields and fundus examination normal Pupils 5 mm OU, sluggish to light, brisk to near. Light/near dissociation of the pupils. No lid retraction Supranuclear saccadic upgaze palsy Full horizontal and downgaze Normal vertical pursuit Convergence normal Convergence retraction nystagmus on upgaze Convergence retraction nystagmus in primary gaze when the eyes return to central position from gaze right, left or down. Skew deviation - right eye hypotropic. No head tilt Vertical oculocephalic reflex normal Deviation of the eyes up under closed lids (Bell's phenomenon) Blood studies: Hematocrit, white blood cell count PT and PTT normal. 1/28/91 Brain MRI: Axial T2W images showed a high signal intensity in the right dorsal midbrain immediately adjacent to the cerebral aqueduct. Axial GRE (T2* scan) showed the lesion ‘blooms' and contains blood degradation products extending from the midline to the right lateral colliculus area. (Figures 1 and 2) Impression: Subacute hemorrhage with bright signal arising from met-hemoglobin products. Diagnosis: Pretectal syndrome Midbrain hemorrhage 1/25/91 A right cerebral angiogram was done, with selective injections of the left internal carotid artery (ICA) and right vertebral artery (VA). The right VA showed no evidence of arteriovenous shunting or focal vascular abnormality. The left ICA demonstrated a fetal type posterior cerebral artery without any focal abnormalities. By January 31, 1991 the skew deviation had resolved and the patient had no double vision. She was also headache free and ready to go home. She was cautioned never to take aspirin or other medications that might impair coagulation of the blood. The residual neurological findings were: 1.Supranuclear saccadic upgaze palsy 2.Convergence retraction nystagmus 3.Light/near dissociation of the pupils Follow-Up: She was followed up at six monthly intervals for two years and then annually. In 1993 following a syncopal attack at work, she returned for repeat imaging studies. 12/8/93 MRI pre and post gadolinium and axial magnetic susceptibility images were performed. Within the posterior right midbrain there was a 5 mm heterogeneous focus of signal abnormality manifested by low T1 signal intensity and central bright T2 signal intensity with a peripheral rim of dark signal intensity. A subtle area of enhancement was noted at the anterior medial margins suggesting granulation tissue. Impression: Old right midbrain hemorrhage without interval change consistent with a cavernous angioma. In Jan 1994 in an effort to prevent a second midbrain bleed, a consultation was obtained from the MGH Intervention Neuroradiologist, Dr. In Sup Choi. Dr. Choi reviewed the radiological studies and found no dilated blood vessels surrounding the lesion and suspected that the patient hemorrhaged from a small cavernous angioma (CA) as the CA was deep and the patient asymptomatic apart from the inability to look up, he recommended no further studies or procedures. In 1996, at her last visit, the neuron-ophthalmic signs were unchanged. See also: http://content.lib.utah.edu/cdm/ref/collection/ehsl-shw/id/86