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Neurological Rehabilitation

(Kiosk 4) Dorsal Pontine Hemorrhage: A Rare Case of Bilateral Horizontal Gaze Palsy and Peripheral Facial Palsy

Thursday, November 16, 2023
12:45 PM – 2:15 PM CT

    Primary Author(s)

  • Lyla Khan, MD

    NRMP Candidate
    St. George's University School of Medicine
    Old Westbury, New York

    • Co-Author(s)

  • Anam Purewal, MD (she/her/hers)

    Resident
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

  • Jason Do, DO

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    333 Schermerhorn st, Apt 10P, New York

  • Miriam Bekhit, MD, Other

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

  • GK

    Getahun Kifle, MD

    Attending Physician
    n/a
    Brooklyn, New York

  • SA

    Sanjeev Agarwal, MD

    Program Director
    SUNY Downstate Medical Center
    Brooklyn, New York

Case Diagnosis: Hemorrhagic cerebral vascular accident (CVA) of the dorsal pontine tegmentum

Case Description or Program Description: 39-year-old female with a past medical history of uncontrolled hypertension, prior CVA with no residual effects, and chronic kidney disease presented with altered mental status and slurred speech, found to have a stroke secondary to hypertensive emergency. When medically stable, she was admitted for acute rehabilitation.

Setting: Inpatient rehabilitation facility

Assessment/Results: Physical examination findings included right post-aurical tenderness to palpation, decreased sensation to the left side, bilateral dysmetria, hyperreflexia on the left side throughout, bilateral gaze palsy, right-sided cranial nerve VII deficits, dysarthria, and dysphagia. Head CT scan revealed a focal pontine hemorrhage involving the right facial nerve nucleus, right paramedian pontine reticular formation (PPRF), and bilateral medial longitudinal fasciculus (MLF). Further imaging was warranted given this patient’s unusual gaze and facial nerve presentation. MRI brain imaging was done to evaluate for inflammatory or mass lesions that could further explain these findings, but no other lesions were noted.

Discussion (relevance): Horizontal gaze palsy can be caused by lesions to structures found within the pontine tegmentum of the brainstem, including the PPRF, abducens nucleus, and MLF. These structures control lateral eye movements, so disruption to the pathway will result in some form of gaze palsy. Facial nerve fibers additionally are proximal to these structures and may be affected. Literature review revealed only one documented case of bilateral gaze palsy with facial paresis secondary to CVA, and ischemic-type at that. Bilateral horizontal gaze palsy is a rare presentation and can be a consequence of infarction, hemorrhage, inflammatory lesions like in multiple sclerosis, or mass lesions like tuberculomas or tumor metastases.

Conclusions: This case demonstrates the importance of recognizing the affected neuroanatomy of a hemorrhagic pontine lesion, in addition to a thorough work-up to rule out common causes of peripheral facial nerve disruptment.