Abstract Introduction Vertical gaze palsy is a recognized manifestation of midbrain lesions. It rarely is a consequence of unilateral thalamic infarction. Case presentation We report the case of a 48-year-old African-American woman who presented to our facility with vertical gaze palsy and evidence of left medial thalamic infarct on diffusion-weighted imaging without coexisting midbrain ischemia. The etiology of infarct was determined to be small vessel disease after extensive investigation. Conclusions This report suggests a possible role of the thalamus as a vertical gaze control center. Clinicoradiological studies are needed to further define the role of the thalamus in vertical gaze control.</p

A Guberman

Christos Sidiropoulos

E Margolin

I Meissner

J Bogousslavsky

J Schlag

JM Clark

M Gentilini

MM van der Graaff

Muhib Khan

P Castaigne

Panayiotis Mitsias

S Blitshteyn

S Weidauer

English

PubMed

Springer - Publisher Connector

Unilateral thalamic infarction presenting as vertical gaze palsy: a case report

Abstract
Introduction
Vertical gaze palsy is a recognized manifestation of midbrain lesions. It rarely is a consequence of unilateral thalamic infarction.
Case presentation
We report the case of a 48-year-old African-American woman who presented to our facility with vertical gaze palsy and evidence of left medial thalamic infarct on diffusion-weighted imaging without coexisting midbrain ischemia. The etiology of infarct was determined to be small vessel disease after extensive investigation.
Conclusions
This report suggests a possible role of the thalamus as a vertical gaze control center. Clinicoradiological studies are needed to further define the role of the thalamus in vertical gaze control

Khan, Muhib

Sidiropoulos, Christos

Mitsias, Panayiotis

Digital Commons@Wayne State University

Wayne State UniversityWayne State University Associated BioMed Central Scholarship2011Unilateral thalamic infarction presenting as verticalgaze palsy: a case reportMuhib KhanHenry Ford Hospital, mkhan4@hfhs.orgChristos SidiropoulosHenry Ford Hospital, csidiro1@hfhs.orgPanayiotis MitsiasHenry Ford Hospital, mitsias@neuro.hfh.eduRecommended CitationKhan et al.: Unilateral thalamic infarction presenting as vertical gaze palsy: a case report. Journal of Medical Case Reports 2011 5:535.The mechanism of vertical gaze paresis with unilateral lesions is uncertain but we can speculate on the possibi- lity of decussation ofthe frontobulbar fibers in the med- ia l tha lamus , as suggested in a case ser ies of tha lam ic infarctions presenting as vertica l gazepalsies [9] . The neuroimaging study results from our patient revealed no m i db r a in l e s io n . T h e r e h a s b e en a p r e v io u s c a se reported of transient vertical gaze palsy with resolution of symptoms within three hours, highlighting the role of the thalamus invertical gaze [10]. Conclusions The combination of vertical gaze paresis and skew devia- t ion , prev ious ly be l ieved to be po int ing toa bra instem lesion, may now be attributed to a broader spectrum of anatomical areas. However, more cases correlating MRI f ind ing sw i th c l in ica l p re sen ta t ion s a s a t temp ted by Weidauer et al. need to be studied in order to establish the role of the thalamus invertical gaze as either a cross- roads or an actual control center [11]. Consent Written informed consent was obtained from the patientfor publication of this case report and any accompany- ing images . A copy o f the writ ten consent is available for review by the Editor-in-Chief of this journal. Authorsâ€™ contributions MK was involved in the diagnosis and treatment of our patient, and wrote themanuscript. CS was involved in the diagnosis of our patient and helped with revising the manuscript. PS was involved in the diagnosisand management of our patient and helped in revising the manuscript. All authors read and approved the final manuscript. CompetingCASE REPORT Open AccessUnilateral thalamic infarction presenting asvertical gaze palsy: a case reportMuhib Khan*, Christos Sidiropoulos and Panayiotis MitsiasAbstractIntroduction: Vertical gaze palsy is a recognized manifestation of midbrain lesions. It rarely is a consequence ofunilateral thalamic infarction.Case presentation: We report the case of a 48-year-old African-American woman who presented to our facilitywith vertical gaze palsy and evidence of left medial thalamic infarct on diffusion-weighted imaging withoutcoexisting midbrain ischemia. The etiology of infarct was determined to be small vessel disease after extensiveinvestigation.Conclusions: This report suggests a possible role of the thalamus as a vertical gaze control center.Clinicoradiological studies are needed to further define the role of the thalamus in vertical gaze control.IntroductionVertical gaze palsy is usually associated with lesions of themesencephalic rostral interstitial nucleus of the mediallongitudinal fasiculus, the interstitial nucleus of Cajal, theposterior commissure and the peri-aqueductal gray matter.Rarely, vertical gaze palsies can be a manifestation of para-median thalamic infarction [1-3]. Here, we describe thecase of a patient presenting with upward gaze palsy sec-ondary to isolated medial thalamic infarct.Case presentationA 48-year-old African-American woman with diabetes,hypertension and hyperlipidemia presented to our facilitywith acute onset of dizziness and vertical diplopia. A phy-sical examination revealed upward gaze paresis, whichcould be overcome by the doll’s eye maneuver and skewdeviation of the right eye. A magnetic resonance imaging(MRI) scan, which was performed 12 hours after the onsetof symptoms, showed an acute left paramedian thalamicinfarct (Figure 1, Figure 2 and 3) without associated mid-brain lesions (Figure 4), and a chronic right cerebellarinfarct. Stenosis of the right vertebral artery at the C4transverse foramen secondary to extrinsic osteophytecompression was seen on magnetic resonance angiographyand confirmed by catheter angiography. There was slightworsening of the degree of narrowing when the head wasrotated to the right, but there was no flow limitation dur-ing the catheter angiography. No dissection of the verteb-ral arteries was noticed.A transesophageal echocardiogram revealed an ejec-tion fraction of 55% with no atrial or ventricular throm-bus or intracardiac shunt. The etiology of stroke wasthought to be due to small vessel disease secondary touncontrolled diabetes and hypertension. Treatment withaspirin, simvastatin, and tight hypertension and diabetescontrol was initiated. No neuropsychological testing wasperformed.DiscussionThis is a report of a rare acute left medial thalamicinfarction manifesting as supranuclear upward gaze palsyand skew deviation. A few previous reports havedescribed vertical gaze palsies in patients with unilateralor bilateral paramedian thalamic infarction, but attribu-ted the gaze palsy to a coexisting midbrain lesion [4],identified primarily at autopsy. An important clinical fea-ture in our patient was the skew deviation, which hasbeen reported with thalamic infarctions [5].The medial thalamus is supplied by perforatingbranches arising from the basilar communicating arteryand posterior cerebral arteries. The midbrain is sparedbecause the superior and inferior paramedian* Correspondence: mkhan4@hfhs.orgDepartment of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard,Detroit, MI, USAKhan et al. Journal of Medical Case Reports 2011, 5:535http://www.jmedicalcasereports.com/content/5/1/535 JOURNAL OF MEDICALCASE REPORTS© 2011 Khan et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.mesencephalic arteries arise separately from each otherfrom the basilar communicating artery [6].The supranuclear pathways involved in vertical gazeare not well understood. Studies on primates reveal thatthe frontal eye fields traverse the medial thalamus [7]. Also, the internal medullary lamina has reciprocal con-nections with the frontal and supplementary eye fields.Interruption of supranuclear fibers as they traverse themedial thalamus en route to the pretectal and prerubralareas [3,8] could possibly lead to vertical gaze paresis.Figure 1 Diffusion-weighted image showing an acute ischemicinfarct in the left medial thalamus.Figure 2 T2-weighted image of the left medial thalamic infarct.Figure 3 T2 fluid attenuated inversion recovery (FLAIR) imageof the left medial thalamic infarct.Figure 4 Diffusion-weighted image of midbrain with noischemia.Khan et al. Journal of Medical Case Reports 2011, 5:535http://www.jmedicalcasereports.com/content/5/1/535Page 2 of 3The mechanism of vertical gaze paresis with unilaterallesions is uncertain but we can speculate on the possibi-lity of decussation of the frontobulbar fibers in the med-ial thalamus, as suggested in a case series of thalamicinfarctions presenting as vertical gaze palsies [9]. Theneuroimaging study results from our patient revealed nomidbrain lesion. There has been a previous casereported of transient vertical gaze palsy with resolutionof symptoms within three hours, highlighting the role ofthe thalamus in vertical gaze [10].ConclusionsThe combination of vertical gaze paresis and skew devia-tion, previously believed to be pointing to a brainstemlesion, may now be attributed to a broader spectrum ofanatomical areas. However, more cases correlating MRIfindings with clinical presentations as attempted byWeidauer et al. need to be studied in order to establishthe role of the thalamus in vertical gaze as either a cross-roads or an actual control center [11].ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompany-ing images. A copy of the written consent is availablefor review by the Editor-in-Chief of this journal.Authors’ contributionsMK was involved in the diagnosis and treatment of our patient, and wrotethe manuscript. CS was involved in the diagnosis of our patient and helpedwith revising the manuscript. PS was involved in the diagnosis andmanagement of our patient and helped in revising the manuscript. Allauthors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 5 March 2011 Accepted: 31 October 2011Published: 31 October 2011References1. Bogousslavsky J, Miklossy J, Deruaz JP, Regli F, Assal G: Unilateral leftparamedian infarction of thalamus and midbrain: a clinico-pathologicalstudy. J Neurol Neurosurg Psychiatry 1986, 49:686-694.2. Castaigne P, Lhermitte F, Buge A, Escourolle R, Hauw JJ, Lyon-Caen O:Paramedian thalamic and midbrain infarct: clinical andneuropathological study. Ann Neurol 1981, 10:127-148.3. Gentilini M, De Renzi E, Crisi G: Bilateral paramedian thalamic arteryinfarcts: report of eight cases. J Neurol Neurosurg Psychiatry 1987,50:900-909.4. van der Graaff MM, Vanneste JA, Davies GA: Unilateral thalamic infarctionand vertical gaze palsy: cause or coincidence? J Neuroophthalmol 2000,20:127-129.5. Margolin E, Hanifan D, Berger MK, Ahmad OR, Trobe JD, Gebarski SS: Skewdeviation as the initial manifestation of left paramedian thalamicinfarction. J Neuroophthalmol 2008, 28:283-286.6. Meissner I, Sapir S, Kokmen E, Stein SD: The paramedian diencephalicsyndrome: a dynamic phenomenon. Stroke 1987, 18:380-385.7. Schlag J, Schlag-Rey M: Neurophysiology of eye movements. Adv Neurol1992, 57:135-147.8. Guberman A, Stuss D: The syndrome of bilateral paramedian thalamicinfarction. Neurology 1983, 33:540-546.9. Clark JM, Albers GW: Vertical gaze palsies from medial thalamicinfarctions without midbrain involvement. Stroke 1995, 26:1467-1470.10. Blitshteyn S, Hentschel K, Czervionke LF, Eidelman BH: Transient verticaldiplopia and nystagmus associated with acute thalamic infarction. ClinImaging 2006, 30:54-56.11. Weidauer S, Nichtweiss M, Zanella FE, Lanfermann H: Assessment ofparamedian thalamic infarcts: MR imaging, clinical features andprognosis. Eur Radiol 2004, 14:1615-1626.doi:10.1186/1752-1947-5-535Cite this article as: Khan et al.: Unilateral thalamic infarction presentingas vertical gaze palsy: a case report. Journal of Medical Case Reports 20115:535.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitKhan et al. Journal of Medical Case Reports 2011, 5:535http://www.jmedicalcasereports.com/content/5/1/535Page 3 of 3

The mechanism of vertical gaze paresis with unilateral lesions is uncertain but we can speculate on the possibi- lity of decussation of the frontobulbar fibers in the med- ia l tha lamus, as suggested in a case ser ies of tha lam ic infarctions presenting as vertica l gaz

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Journal of Medical Case Reports

Abstract Introduction Vertical gaze palsy is a recognized manifestation of midbrain lesions. It rarely is a consequence of unilateral thalamic infarction. Case presentation We report the case of a 48-year-old African-American woman who presented to our facility with vertical gaze palsy and evidence of left medial thalamic infarct on diffusion-weighted imaging without coexisting midbrain ischemia. The etiology of infarct was determined to be small vessel disease after extensive investigation. Conclusions This report suggests a possible role of the thalamus as a vertical gaze control center. Clinicoradiological studies are needed to further define the role of the thalamus in vertical gaze control.</p

Mitsias Panayiotis

Sidiropoulos Christos

Khan Muhib

Directory of Open Access Journals

CASE REPORT Open Access
Unilateral thalamic infarction presenting as
vertical gaze palsy: a case report
Muhib Khan*, Christos Sidiropoulos and Panayiotis Mitsias
Abstract
Introduction: Vertical gaze palsy is a recognized manifestation of midbrain lesions. It rarely is a consequence of
unilateral thalamic infarction.
Case presentation: We report the case of a 48-year-old African-American woman who presented to our facility
with vertical gaze palsy and evidence of left medial thalamic infarct on diffusion-weighted imaging without
coexisting midbrain ischemia. The etiology of infarct was determined to be small vessel disease after extensive
investigation.
Conclusions: This report suggests a possible role of the thalamus as a vertical gaze control center.
Clinicoradiological studies are needed to further define the role of the thalamus in vertical gaze control.
Introduction
Vertical gaze palsy is usually associated with lesions of the
mesencephalic rostral interstitial nucleus of the medial
longitudinal fasiculus, the interstitial nucleus of Cajal, the
posterior commissure and the peri-aqueductal gray matter.
Rarely, vertical gaze palsies can be a manifestation of para-
median thalamic infarction [1-3]. Here, we describe the
case of a patient presenting with upward gaze palsy sec-
ondary to isolated medial thalamic infarct.
Case presentation
A 48-year-old African-American woman with diabetes,
hypertension and hyperlipidemia presented to our facility
with acute onset of dizziness and vertical diplopia. A phy-
sical examination revealed upward gaze paresis, which
could be overcome by the doll’s eye maneuver and skew
deviation of the right eye. A magnetic resonance imaging
(MRI) scan, which was performed 12 hours after the onset
of symptoms, showed an acute left paramedian thalamic
infarct (Figure 1, Figure 2 and 3) without associated mid-
brain lesions (Figure 4), and a chronic right cerebellar
infarct. Stenosis of the right vertebral artery at the C4
transverse foramen secondary to extrinsic osteophyte
compression was seen on magnetic resonance angiography
and confirmed by catheter angiography. There was slight
worsening of the degree of narrowing when the head was
rotated to the right, but there was no flow limitation dur-
ing the catheter angiography. No dissection of the verteb-
ral arteries was noticed.
A transesophageal echocardiogram revealed an ejec-
tion fraction of 55% with no atrial or ventricular throm-
bus or intracardiac shunt. The etiology of stroke was
thought to be due to small vessel disease secondary to
uncontrolled diabetes and hypertension. Treatment with
aspirin, simvastatin, and tight hypertension and diabetes
control was initiated. No neuropsychological testing was
performed.
Discussion
This is a report of a rare acute left medial thalamic
infarction manifesting as supranuclear upward gaze palsy
and skew deviation. A few previous reports have
described vertical gaze palsies in patients with unilateral
or bilateral paramedian thalamic infarction, but attribu-
ted the gaze palsy to a coexisting midbrain lesion [4],
identified primarily at autopsy. An important clinical fea-
ture in our patient was the skew deviation, which has
been reported with thalamic infarctions [5].
The medial thalamus is supplied by perforating
branches arising from the basilar communicating artery
and posterior cerebral arteries. The midbrain is spared
because the superior and inferior paramedian* Correspondence: mkhan4@hfhs.org
Department of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard,
Detroit, MI, USA
Khan et al. Journal of Medical Case Reports 2011, 5:535
http://www.jmedicalcasereports.com/content/5/1/535 JOURNAL OF MEDICAL
CASE REPORTS
© 2011 Khan et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
mesencephalic arteries arise separately from each other
from the basilar communicating artery [6].
The supranuclear pathways involved in vertical gaze
are not well understood. Studies on primates reveal that
the frontal eye fields traverse the medial thalamus [7]. Also, the internal medullary lamina has reciprocal con-
nections with the frontal and supplementary eye fields.
Interruption of supranuclear fibers as they traverse the
medial thalamus en route to the pretectal and prerubral
areas [3,8] could possibly lead to vertical gaze paresis.
Figure 1 Diffusion-weighted image showing an acute ischemic
infarct in the left medial thalamus.
Figure 2 T2-weighted image of the left medial thalamic infarct.
Figure 3 T2 fluid attenuated inversion recovery (FLAIR) image
of the left medial thalamic infarct.
Figure 4 Diffusion-weighted image of midbrain with no
ischemia.
Khan et al. Journal of Medical Case Reports 2011, 5:535
http://www.jmedicalcasereports.com/content/5/1/535
Page 2 of 3
The mechanism of vertical gaze paresis with unilateral
lesions is uncertain but we can speculate on the possibi-
lity of decussation of the frontobulbar fibers in the med-
ial thalamus, as suggested in a case series of thalamic
infarctions presenting as vertical gaze palsies [9]. The
neuroimaging study results from our patient revealed no
midbrain lesion. There has been a previous case
reported of transient vertical gaze palsy with resolution
of symptoms within three hours, highlighting the role of
the thalamus in vertical gaze [10].
Conclusions
The combination of vertical gaze paresis and skew devia-
tion, previously believed to be pointing to a brainstem
lesion, may now be attributed to a broader spectrum of
anatomical areas. However, more cases correlating MRI
findings with clinical presentations as attempted by
Weidauer et al. need to be studied in order to establish
the role of the thalamus in vertical gaze as either a cross-
roads or an actual control center [11].
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A copy of the written consent is available
for review by the Editor-in-Chief of this journal.
Authors’ contributions
MK was involved in the diagnosis and treatment of our patient, and wrote
the manuscript. CS was involved in the diagnosis of our patient and helped
with revising the manuscript. PS was involved in the diagnosis and
management of our patient and helped in revising the manuscript. All
authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 5 March 2011 Accepted: 31 October 2011
Published: 31 October 2011
References
1. Bogousslavsky J, Miklossy J, Deruaz JP, Regli F, Assal G: Unilateral left
paramedian infarction of thalamus and midbrain: a clinico-pathological
study. J Neurol Neurosurg Psychiatry 1986, 49:686-694.
2. Castaigne P, Lhermitte F, Buge A, Escourolle R, Hauw JJ, Lyon-Caen O:
Paramedian thalamic and midbrain infarct: clinical and
neuropathological study. Ann Neurol 1981, 10:127-148.
3. Gentilini M, De Renzi E, Crisi G: Bilateral paramedian thalamic artery
infarcts: report of eight cases. J Neurol Neurosurg Psychiatry 1987,
50:900-909.
4. van der Graaff MM, Vanneste JA, Davies GA: Unilateral thalamic infarction
and vertical gaze palsy: cause or coincidence? J Neuroophthalmol 2000,
20:127-129.
5. Margolin E, Hanifan D, Berger MK, Ahmad OR, Trobe JD, Gebarski SS: Skew
deviation as the initial manifestation of left paramedian thalamic
infarction. J Neuroophthalmol 2008, 28:283-286.
6. Meissner I, Sapir S, Kokmen E, Stein SD: The paramedian diencephalic
syndrome: a dynamic phenomenon. Stroke 1987, 18:380-385.
7. Schlag J, Schlag-Rey M: Neurophysiology of eye movements. Adv Neurol
1992, 57:135-147.
8. Guberman A, Stuss D: The syndrome of bilateral paramedian thalamic
infarction. Neurology 1983, 33:540-546.
9. Clark JM, Albers GW: Vertical gaze palsies from medial thalamic
infarctions without midbrain involvement. Stroke 1995, 26:1467-1470.
10. Blitshteyn S, Hentschel K, Czervionke LF, Eidelman BH: Transient vertical
diplopia and nystagmus associated with acute thalamic infarction. Clin
Imaging 2006, 30:54-56.
11. Weidauer S, Nichtweiss M, Zanella FE, Lanfermann H: Assessment of
paramedian thalamic infarcts: MR imaging, clinical features and
prognosis. Eur Radiol 2004, 14:1615-1626.
doi:10.1186/1752-1947-5-535
Cite this article as: Khan et al.: Unilateral thalamic infarction presenting
as vertical gaze palsy: a case report. Journal of Medical Case Reports 2011
5:535.
Submit your next manuscript to BioMed Central
and take full advantage of: 
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at 
www.biomedcentral.com/submit
Khan et al. Journal of Medical Case Reports 2011, 5:535
http://www.jmedicalcasereports.com/content/5/1/535
Page 3 of 3


Albers GW: Vertical gaze palsies from medial thalamic infarctions without midbrain involvement. Stroke

Assal G: Unilateral left paramedian infarction of thalamus and midbrain: a clinico-pathological study.

Assessment of paramedian thalamic infarcts: MR imaging, clinical features and prognosis. Eur Radiol

Czervionke LF, Eidelman BH: Transient vertical diplopia and nystagmus associated with acute thalamic infarction. Clin Imaging

De Renzi E, Crisi G: Bilateral paramedian thalamic artery infarcts: report of eight cases.

GA: Unilateral thalamic infarction and vertical gaze palsy: cause or coincidence?

Gebarski SS: Skew deviation as the initial manifestation of left paramedian thalamic infarction.

Lyon-Caen O: Paramedian thalamic and midbrain infarct: clinical and neuropathological study. Ann Neurol

Schlag-Rey M: Neurophysiology of eye movements.

SD: The paramedian diencephalic syndrome: a dynamic phenomenon. Stroke

Stuss D: The syndrome of bilateral paramedian thalamic infarction. Neurology

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Unilateral thalamic infarction presenting as vertical gaze palsy: a case report

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