Eight-and-a-half syndrome: an unusual presentation of brainstem infarction

Abstract

A 68-year-old man known to have non-insulin-dependant diabetes, hypertension and hypercholesterolemia presented with a 2-day history of abnormal sensation on the left side of his face and associated weakness of his right arm and leg. The symptoms presented with a sudden onset and had a stuttering course over the next 2 days at which point he presented to hospital. Initial examination revealed a left lower motor neurone VII nerve type weakness (Figure 1) with associated upper motor neurone type hemiparesis of his right upper and lower limbs. Further eye examination revealed total left horizontal gaze paresis and partial right horizontal gaze paresis with limitation of adduction of the right eye. Right eye abduction and vertical eye movements were preserved (Figures 2–4). Jump saccades were present on right gaze and absent on left gaze. ... His initial investigations revealed normal electrolytes, blood profile and liver functions. An autoimmune screen, ESR and treponemal antibody testing did not reveal any abnormality either. Diffusion weighted magnetic resonance imaging revealed a left caudal pontine infarct (Figure 5). Further CT angiography did not reveal any evidence of fresh vertebro-basilar thrombi or vertebral dissection.