A 78-year-old woman with a history of diabetes mellitus and hypertension sought care because of sudden-onset dysarthria, left face and arm weakness, and right gaze preference. Shortly afterward, the patient developed bilateral facial weakness, with her gaze returning to the midline position. She had bilateral ptosis, near-total ophthalmoplegia, anarthria, and an inability to move her tongue and subsequently required intubation for airway protection. Attempts to extubate the patient were unsuccessful, and tracheotomy was necessary. Two weeks after presentation, the patient was alert and followed simple commands. She had relatively preserved strength in all extremities but no change in profound bilateral facial weakness (Figure, D). She had limited volitional ability to move her eyes vertically (Figure, E and F) or horizontally. This could be overcome easily with oculocephalic maneuvers (Figure, G-J; ). A computed tomography angiogram revealed an occlusion of the left middle cerebral artery in the M1 segment and the right middle cerebral artery in the superior M2 segment. Magnetic resonance imaging of the brain showed bilateral infarcts in the posterior frontal lobe involving the frontal operculum and subcortical tracts (Figure, A-C) without involvement of the thalamus, basal ganglia, or brainstem.
Figure. Axial views on brain magnetic resonance imaging and limited volitional eye movements. Diffusion weight imaging revealed bilateral frontal lobe infarcts (A-C). On examination, the patient had bilateral facial weakness (D) and limited volitional rightward (E) and leftward (F) gaze. With passive head turning, the eye movement was intact to the rightward (G), leftward (H), upward (I), and downward (J) gaze.
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Limited Volitional Eye Movements
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