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Images in Neurology |

Unusual Third Nerve Synkinesis Due to Midbrain Injury

Guillaume Taieb, MD; Dimitri Renard, MD; Luc Jeanjean, MD; Giovanni Castelnovo, MD; Pierre Labauge, MD, PhD
Arch Neurol. 2011;68(7):948-949. doi:10.1001/archneurol.2011.140.
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A 40-year-old woman presented with coma after head injury. Computed tomographic imaging revealed a parenchymal midbrain hemorrhage. The patient regained consciousness with palsy of all vertical eye movements (ie, saccades, smooth pursuit, optokinetic and vestibulo-ocular reflexes, and Bell phenomenon), bilateral ptosis, and bilateral dilated and unreactive pupils associated with paralysis of the near-vision triad. Results of visual acuity and direct ophthalmoscopic testing were normal. Four months later, results of ocular motility testing showed persistent palsy of all vertical eye movements. Also, horizontal eye movements displayed, in both directions, palpebral fissure widening of the adducting eye associated with palpebral fissure narrowing of the abducting eye (consistent with bilateral symmetrical acquired third nerve synkinesis) without globe retraction (video). Results of forced duction testing were normal. Orbital magnetic resonance imaging results were normal (including absence of medial rectus muscle entrapment). Brain magnetic resonance imaging revealed a symmetrical paramedian brainstem lesion (Figure).

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Figure. Magnetic resonance imaging of a symmetrical paramedian brainstem lesion (arrow) (axial [A] and sagittal [B] T1-weighted images and axial T2- [C] and T2*[D]–weighted images).




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