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Case Reports
. 2021 Sep 8;13(9):e17819.
doi: 10.7759/cureus.17819. eCollection 2021 Sep.

Midbrain Ischemic Strokes Presenting as Isolated Internuclear Opthalmoplegia

Dalys Haymes  1 , Matthew Jenson  2 , Chidi Nwachukwu  2 , Peter Fiester  1
Affiliations
Case Reports

Midbrain Ischemic Strokes Presenting as Isolated Internuclear Opthalmoplegia

Dalys Haymes et al. Cureus. .

Abstract

Stroke can present with unique neurologic symptoms, which can be used to help determine the location of the stroke. Internuclear ophthalmoparesis (INO), also known as internuclearophthalmoplegia, is a distinct gaze abnormality with impaired horizontal eye movements with compromised adduction of the affected eye, and abduction nystagmus of the contralateral eye. Infarcts involving the medial longitudinal fasciculus in either the pons or midbrain can result in INO. We present two cases of midbrain ischemic stroke, which presented as isolated INO. The midbrain has a unique and intricate vascular supply including branches from the basilar, superior cerebellar, posterior cerebral, posterior communicating, anterior choroidal, and posterior choroidal arteries, which is reviewed. Infarcts involving the paramedian midbrain, which is supplied by short circumferential arteries and penetrating branches arising from the posterior cerebral artery and superior cerebellar artery, can result in INO.

Keywords: infarct; internuclear ophthalmoparesis; midbrain; stroke; vascular supply.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Case 1 MRI
Axial MRI images including (A) ADC, (B) DWI, and (C) FLAIR.  Images demonstrate restricted diffusion with associated FLAIR signal abnormality in the right paramedian midbrain. ADC, apparent diffusion coefficient; DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery.
Figure 2
Figure 2. Case 2 MRI
Axial MRI images including (A) ADC, (B) DWI, and (C) FLAIR.  Images demonstrate a small infarct in the right periaqueductal white matter along the anatomic course of the right MLF, without definite FLAIR correlate at this time. ADC, apparent diffusion coefficient; DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; MLF, medial longitudinal fasciculus.
Figure 3
Figure 3. Vascular Supply of the Midbrain
LMB, lateral mesencephalic branches; ST, spinoreticular tract; ML, medial lemniscus; CTT, central tegmental tract; SN, substantia nigra; RN, red nucleus; CP, cerebral peduncular; SCA, superior cerebellar artery; IMMB, inferior medial mesencephalic branch; FT, frontopontine tract; TC, tractus corticobulbrais; CT, corticospinal tract; DMB, dorsal mesencephalic branch. Image used with permission from the CC BY license from https://www.researchgate.net/publication/336800360_An_Analysis_of_Clinical_Characteristics_of_Rare_Bilateral_Cerebral_Peduncular_Infarction.
See this image and copyright information in PMC

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