WELCOME

A ‘60 yr’ Man

with

Acute ‘Double Vision’ &

‘Difficulty in Walking’
Presented By:
Dr. Ahmed Tanjimul Islam (Ovi)
MD (Thesis Student) Neuromedicine
 Particulars of the Patient:
• Name: Azizur Rahman
• Age: 60 yrs
• Occupation: Shopkeeper
• Marital Status: Married
• Address: Poba, Rajshahi
• Date of Admission: 18/02/19
 Chief Complaints
• Double Vision for 2 months
 Chief Complaints
• Double Vision for 2 months
• Difficulty in Walking for 2 months
 H/O Presenting Illness
• According to the statement of the patient, he
was relatively alright 2 months back.
• Then he suddenly developed Double Vision
(Diplopia) which was painless, bilateral & for
horizontal eye movements.
• The Diplopia was aggravated on looking at
right side.
 H/O Presenting Illness
• The patient also complains of ‘Difficulty in
Walking’ for same duration.

• The Walking Difficulty was sudden onset, non-

progressive & tendency to fall sideways, which
was more prominent when walking in a narrow
passage.

• The patient also complains of intermittent Vertigo

& decreased Sleep.
 H/O Presenting Illness
• Diplopia was NOT associated with diurnal
variation, eye pain, vision loss or facial numbness.

• Difficulty in Walking was NOT associated with

hemiplegia, sensory loss, speech disturbance or
involuntary movements.

• Vertigo was mild, NOT associated with tinnitus or

vomiting & not hampering daily activities.
 H/O Presenting Illness
• The patient is Hypertensive for 7 years &
Diabetic for 4 years.

• He was diagnosed as a case of ‘COPD’ 8 years back &

admitted to upazilla hospital for 4 times for respiratory
distress & restlessness (uncontrolled hypertension &
diabetes).

• There was NO history of headache, anorexia, weight loss

or vomiting. There was also NO history of fever, seizure,
tinnitus or recurrence of present symptoms.
 NO
Features absent in admission:
• Headache, Vomiting
• Progressive
• Weight loss
• Recurrence (Relapsing-remitting)
• Vision loss
• Seizure
• Loss of consciousness
• Tinnitus
• History of Surgery, Head injury
 History of Past Illness

• No history of :
• Asthma
• Jaundice
• Tuberculosis (TB)
• Allergy
• Trauma, Surgery
 `
Family History:
• All family members are well.

Drug/ Treatment History: (irregular)

• Metformin 500 (night)
• Atenolol 50 mg (night)
• Frusemide (Occasional)
• Theophyline 200 (night), Salbutamol inhaler
Personal History:
• Smoker:
10 pack year (10 sticks/day for 20 yrs)
• Bettel Nuts: 10/day

Socio Economic History:

• Lives in Semi pakka House.
• Tube well

Immunization & Allergy History:

• No history.
 General
Examination:
General Examination
Appearance Anxious/ Ill looking
Body Built Lean Thin
Co operation Co operative
Dicubitus On choice
Anaemia Absent
Jaundice Absent
Cyanosis Absent
Oedema Mild (ankle)
Dehydration Absent
Koilonychia Absent
Leuconychia Absent
General Examination
Appearance Anxious/ Ill looking
Body Built Lean Thin
Co operation Co operative
Dicubitus On choice
Anaemia Absent
Jaundice Absent
Cyanosis Absent
Oedema Mild (ankle)
Dehydration Absent
Koilonychia Absent
Leuconychia Absent
Lymph Nodes (Cervical, Non Palpable
Axillary, Inguinal)
Bony Tenderness Absent
Respiratory rate 20 / min
Pulse 60 / min
Blood pressure 180/90 mm Hg
Postural drop Absent
Temperature 98.5 F
Weight 72 Kg
Lymph Nodes (Cervical, Non Palpable
Axillary, Inguinal)
Bony Tenderness Absent
Respiratory rate 20 / min
Pulse 60 / min
Blood pressure 180/90 mm Hg
Postural drop Absent
Temperature 98.5 F
Weight 52 Kg
 SYSTEMIC
EXAMINATION
 Higher Cerebral Function

Consciousness Level of Consciousness Normal

Attention
Concentration
Orientation

Affect Mood, Behavior Normal

Cognition Language Normal
Memory
Reasoning
Judgment
Abstract Thinking,
Insight
MMSE 28/30 Normal
Emotional Lability Absent
 Higher Cerebral Function

Consciousness Level of Consciousness Normal

Attention
Concentration
Orientation

Affect Mood, Behavior Normal

Cognition Language Normal
Memory
Reasoning
Judgment
Abstract Thinking,
Insight
MMSE 28/30 Normal
Emotional Lability Absent
 Cranial Nerve Examination
Optic (II) Visual Acuity: Normal
Fundoscopy:
Dot & blot hemorrhage (both eye)
Cotton wool spot (7 O clock)
Trigeminal (V)
3rd, 4th, 6th

8th, 9th, 10th, 11th, 12th

 Cranial Nerve Examination
Optic (II) Visual Acuity: Normal
Fundoscopy:
Dot & blot hemorrhage (both eye)
Cotton wool spot (7 O clock)
Trigeminal (V) Sensory: intact
Jaw jerk: normal
3rd, 4th, 6th

8th, 9th, 10th, 11th, 12th

 Cranial Nerve Examination
Optic (II) Visual Acuity: Normal
Fundoscopy:
Dot & blot hemorrhage (both eye)
Cotton wool spot (7 O clock)
Trigeminal (V) Sensory: intact
Jaw jerk: normal
3rd, 4th, 6th Incomplete Ptosis (Rt)
Dilated Pupil (Rt)
Gaze palsy: both eye
Nystagmus: both eye
Diplopia: Horizontal movement
False image: Outer
8th, 9th, 10th, 11th, 12th Normal
Azizul Haque 60 yrs
Upper & Lower Limb Examination:
INSPECTION OF UPPER & Rt & Left
• LOWER LIMB
Inspection
Muscle Atrophy Absent
Thigh, forearm
Fasciculation Absent
Dorsal guttering Absent
Skin Changes Absent
Hair Changes Absent
Scar Mark Absent
Pigmentation Absent
Joint Deformity Absent
 Motor System Examination:
• Bulk of the muscle:
Upper Limb Lower Limb
Right Left Right Left
12cm 12cm 13 cm 12 cm

• Tone: Normal
• Power: MRC Grading
LIMBS Right Left
UPPER LIMB 5 4
LOWER LIMB 5 5
 Reflexes :
Jerks Findings
Deep Reflexes Rt Lf
Planter Flexor Flexor
Ankle ++ ++
Knee ++ ++
Supinator ++ ++
Biceps ++ ++
Triceps ++ ++
Superficial Reflexes
Abdominal, Cremesteric ++ ++
Cornael, conjuctival Reflex ++ ++
 Sensory System Examination
Superficial Sensations: Intact (Normal)
Touch, Pain, Temperature N
Deep Sensations: Intact (Normal)
Proprioception, Vibration N
Discriminative sensory N
function
Steriognosis, Localization N
of touch
Two point discrimination
Co ordination:
• Finger nose test: Normal
• Heel knee test: Normal
• Involuntary movements: Absent

Gower’s Sign: Absent

Rhomber’s test: Negative

Gait:
Wide based gait
Tandem walking: Positive
Tendency to fall towards left side.
Co ordination:
• Finger nose test: Normal
• Heel knee test: Normal
• Involuntary movements: Absent

Gower’s Sign: Absent

Rhomber’s test: Negative

Gait:
• Wide based gait
• Tandem walking: Positive
• Tendency to fall towards right side.
 Nerve Impingement test:
Medial Nerve
Phalans test Negative
Tinel’s sign Negative
Ulner Nerve Test
Fromet’s Sign Negative
Ulnar Stretch Test Negative
Radial Nerve Test
Nerve Thickening Absent
Addson’s Menuaver Negative
Spine Examination
Tenderness Absent

Deformities Absent

Range of motion Absent

Meningeal Signs
Neck rigidity Absent
Kernig’s Sign
Brudzinski’s Sign:
• Cardiovascular system examination:
• Apex Beat: 6th ICS, lateral to MCL
• Heart sounds: Normal.
• Murmur, Thrill: Absent

• Respiratory system examination:

• Trachea: Central
• Breath sound: Vesciular with Prolonged Expiration
• Added sound: No
• Abdominal Examination:
Liver, spleen, kidney : Not palpable
Ascites: Absent

• Muskuoskeletal system examination: NAD

Bony deformity: Absent

• Dermatological Examintaion: NAD

 Positive Findings
YES

• Nystagmus
• Diplopia
• III nerve palsy (Rt)
• Gaze palsy
• Cerebellar Sign:
• Tandem walk: +
• Wide based gait
• Fundoscopy:
• Dot & blot hemorrhage, Cotton wool spots
• Co-morbid findings: DM, HTN, COPD, Ankle oedema
 NO
Features absent in admission:
• Headache, Vomiting
• Progressive
• Weight loss
• Recurrence (Relapsing-remitting)
• Vision loss
• Seizure
• Loss of consciousness
• Tinnitus
• History of Surgery, Head injury
Provisional
Diagnosis

?
DIFFENTIAL
DIAGNOSIS

?
 Differential Diagnosis
D/D
1. Brainstem Stroke
2. ?
3. ?
4. ?
5. ?
 Differential Diagnosis
D/D
1. Brainstem Stroke
2. Brainstem SOL (Space occupying lesion)
3. ?
4. ?
5. ?
 Differential Diagnosis
D/D
1. Brainstem Stroke
2. Brainstem SOL (Space occupying lesion)
3. Demyelination (Brainstem)
4. ?
5. ?
INVESTIGATION:
 1st Line Investigation
• CBC:
• Hb: 14.6 gm/dl
• WBC: 13000/ cumm
• Platelet: 2.6 lac/ cumm
• ESR: 40 mm 1st hour
• CRP: 3.6
• RBS: 19.4 mmo/l
• S. Creatinine: 2.1 mmol/l
• Urine R/E : Normal Study
 1st Line Investigation
• CBC:
• Hb: 14.6 gm/dl
• WBC: 13000/ cumm
• Platelet: 2.6 lac/ cumm
• ESR: 40 mm 1st hour
• CRP: 3.6
• RBS: 24.4 mmo/l
• S. Creatinine: 2.1 mmol/l
• Urine R/E : Normal Study
Chest X ray ECG
ECG
 2 Line Investigations
nd
• :
• Hb A1c: 9.8 %
• TSH: 4.8

• S. Electrolytes: Normal

• Fundal picture:
Dot Blot Hemorrhage (Both eye)
 2 Line Investigations
nd
• :

Imaging Study

• CT Scan Brain

• MRI of Brain (+/- Contrast)

CT Scan Brain: Normal
CT Scan Brain: Normal
MRI of Brain (DWI)
MRI of Brain (DWI)
 Confirmed Diagnosis:

Brainstem
Ischemic Stroke
With
COPD, Hypertension, Diabetes mellitus
 Confirmed Diagnosis:

Midbrain Ischemic Stroke

(Nothnagel Syndrome)
With
COPD, Hypertension, Diabetes
 Management :

General Management Specific Management

• A+B+C
• Control DM, HTN
• COPD management
• Complication Rx
• Co-morbid Rx
 Management :

General Management Specific Management

• A+B+C • Aspirin, Clopidogrel
• Control DM, HTN • Atorvastatin
• COPD management • Insulin
• Complication Rx • Rehabilitation
Physiotherapy,
Occupational therapy
• Co-morbid Rx
Brainstem
Syndromes
DAVIDSON
ABDULLAH (page 518)
Why Brainstem Syndrome important ?
Importance ?
• Prognosis : (Good Vs Bad)
• Treatable acute Medical:
1. Hemorrhage
1. ADEM
2. Abscess
3. Co-morbidity
• Surgical option:
Tumor, Metastasis, Abscess
• Prevention of Complications
1. Aspiration
2. Exposure keratitis, Strabismus
 Why Brainstem Syndrome important
Importance ?
• Prognosis : (Good Vs Bad)
• Treatable acute Medical:
1. Hemorrhage
1. ADEM
2. Abscess
3. Co-morbidity
• Surgical option:
Tumor, Metastasis, Abscess
• Prevention of Complications
1. Aspiration
2. Exposure keratitis, Strabismus.
 Bad Prognosis

Bad Prognosis
1. Bilateral involved
2. >1 Stem involved: (Midbrain, Pons, Medulla)
3. Extensive lesion: (Supra & Infra-tentorial)
4. Co-Morbidity: (Diabetes)
SUSPECT Brainstem Syndrome: All ‘C’
1. Crossed Hemiplegia
2. Cranial Nerve
3. Consciousness
4. Cerebellar
5. Quadriplegia/ Bilateral features
SUSPECT Brainstem Syndrome: All ‘C’
1. Crossed Hemiplegia
2. Cranial Nerve
3. Consciousness
4. Cerebellar
5. Quadriplegia/ Bilateral features

Pontine Lesion: All ‘P’

• Pin-Point Pupil
• Pyrexia
• Para/quadriplegia
 Midbrain Syndromes
Syndrome
• Weber

• Claud

• Benedikt

• Nothnagel

• Perinaud
 Midbrain Syndromes
Syndrome %
• Weber 55 %

• Claud 25 %

• Benedikt 15 %

• Nothnagel 1%

• Perinaud 4%
 Midbrain Syndromes
Syndrome %
• Weber 55 %

• Claud 25 %

• Benedikt 15 %

• Nothnagel 1%

• Perinaud 4%
 Midbrain Syndromes
Syndrome %
• Weber 55 %

• Claud 25 %

• Benedikt 15 %

• Nothnagel 1%

• Perinaud 4%
 Midbrain Syndromes
Syndrome Site CN Tract Signs
• Weber Base of
Midbrain
III CST • III +
• Hemiplegia
• Claud Tegmentum III Red • III
Nucleus • Ataxia, Tremor
• Benedikt Tegmentum III Red • III
Nucleus • Ataxia, Tremor
CST • Hemiplegia
• Nothnagel Tectum III Sup. • III
Cerebellar • Gaze palsy
Peduncle • Ataxia
• Perinaud Dorsal
Midbrain
• Paralysis of Upgaze
& accommodation
• Fixed Pupil
 Midbrain Syndromes
Syndrome Site CN Tract Signs
• Weber Base of
Midbrain
III CST • III +
• Hemiplegia
• Claud’s Tegmentum III Red • III
Nucleus • Ataxia, Tremor
• Benedikt Tegmentum III Red • III
Nucleus • Ataxia, Tremor
CST • Hemiplegia
• Nothnagel Tectum III Sup. • III
Cerebellar • Gaze palsy
Peduncle • Ataxia
• Perinaud Dorsal
Midbrain
• Paralysis of Upgaze
& accommodation
• Fixed Pupil
 Midbrain Syndromes
Syndrome Site CN Tract Signs
• Weber Base of
Midbrain
III CST • III +
• Hemiplegia
• Claud Tegmentum III Red • III
Nucleus • Ataxia, Tremor
• Benedikt Tegmentum III Red • III
Nucleus • Ataxia, Tremor
CST • Hemiplegia
• Nothnagel Tectum III Sup. • III
Cerebellar • Gaze palsy
Peduncle • Ataxia
• Perinaud Dorsal
Midbrain
• Paralysis of Upgaze
& accommodation
• Fixed Pupil
 Midbrain Syndromes
Syndrome Site CN Tract Signs
• Weber Base of
Midbrain
III CST • III +
• Hemiplegia
• Claud Tegmentum III Red • III
Nucleus • Ataxia, Tremor
• Benedikt Tegmentum III Red • III
Nucleus • Ataxia, Tremor
CST • Hemiplegia
• Nothnagel Tectum III Sup. • III
Cerebellar • Gaze palsy
Peduncle • Ataxia
• Perinaud Dorsal
Midbrain
• Paralysis of Upgaze
& accommodation
• Fixed Pupil
???
???
WEBER SYNDROME
???
Perinaud Syndrome
Midbrain Anatomy
Midbrain Anatomy

III Nerve
Nucleus
Midbrain Anatomy

RED
NUCLEUS
Midbrain Anatomy

CST
 Midbrain Anatomy

Weber
 Midbrain Anatomy

Benedikt
Midbrain Anatomy

Claud
 Midbrain Anatomy

Nothnagel
‘MRI’ brainstem stroke
‘MRI’ brainstem stroke
‘DWI’ brainstem stroke
‘DWI’ brainstem stroke
 Brain Stem Syndrome (Pons - Medulla)
Syndromes
PONS
• Milard-Gubler
• Foville

• Raymond
MEDULLA
• Medial Medullary
(Dejerine Syndrome)
• Lateral Medullary
(Wallenburg Syndrome)
 BrainStem
Brain Stem Syndromes
Syndrome (Pons
(Pons- Medulla)
Medulla)
Syndromes CN Signs
PONS
• Milard-Gubler 6, 7 • Hemiplegia
• Foville 6, 7 • Gaze palsy
PPRF • Hemiplegia
• Raymond 6 • Hemiplegia
MEDULLA
• Medial Medullary 12 • Hemiplegia
(Dejerine Syndrome) • Sensory Loss
• Lateral Medullary 9, 10, 11 • Horner’s
(Wallenburg Syndrome) Spinal V • Cerebellar Ataxia
• Pain, Temp Loss
(Contralateral)
 BrainStem
Brain Stem Syndromes
Syndrome (Pons
(Pons- Medulla)
Medulla)
Syndromes CN Signs
PONS
• Milard-Gubler 6, 7 • Hemiplegia
• Foville 6, 7 • Gaze palsy
PPRF • Hemiplegia
• Raymond 6 • Hemiplegia
MEDULLA
• Medial Medullary 12 • Hemiplegia
(Dejerine Syndrome) • Sensory Loss
• Lateral Medullary 9, 10, 11 • Horner’s
(Wallenburg Syndrome) Spinal V • Cerebellar Ataxia
• Pain, Temp Loss
(Contralateral)
???
Milard-Gubler Syndrome
Osmotic Demyelination Syndrome
Osmotic Demyelination Syndrome
Brainstem Glioma
Brainstem Glioma
Brainstem
B Glioma
‘MRS’ to confirm ICSOL
‘MRS’ to confirm ICSOL
Published in ‘Journal of Medicine’ 2020
Pakistan College of Physicians & Surgeons
(PCPS) 2019
Publication in ‘BIRDEM’ Journal 2019
Published 2018
 Take Home Message
• Patient presenting with
1. Eye signs
2. Gaze palsy
3. Cranial nerve palsy &
4. Ataxia
‘Brainstem’ pathology should be a D/D

• Find out if Treatable by medical/surgical.

• Extra support with Bad prognostic factors.

Thank You