A number of syndromes have been reported with small pontine tegmental infarcts including, among others, internuclear ophthalmoplegia (INO), one and a half syndrome (and its derivatives), and isolated sixth and seventh nerve palsies. To our knowledge, the combination of ipsilateral sixth and seventh nerve palsies, ipsilateral INO and vertical gaze restriction has not been reported.
Case Report:
A 51-year-old woman with hypertension, diabetes and a remote left thalamic hemorrhage awoke with horizontal diplopia and right facial droop. Neurologic examination showed no horizontal movement in her right eye, bilateral vertical gaze restriction, and a right lower motor neuron facial paresis. Brain MRI showed a small focus of diffusion restriction in the right pontine tegmentum at the level of the sixth and seventh nuclei and medial longitudinal fasciculus (MLF). FLAIR sequences demonstrated extensive small vessel disease. Putative mechanism of the infarct was small vessel disease.