Generic placeholder image

Current Medical Imaging

Editor-in-Chief

ISSN (Print): 1573-4056
ISSN (Online): 1875-6603

Case Report

Internuclear Ophthalmoplegia as an Isolated Symptom of Brainstem Wake-up Stroke Responsive to Intravenous Thrombolysis: Evidence from MRI

Author(s): Gaetano Barbagallo*, Marcella Caggiula, Annalisa Rizzo, Vita Direnzo, Angela Lupo, Antonio Fasano, Cosimo Angelo Greco, Alfredo Pauciulo, Antonio Saponaro, Adriana Paladini and Leonardo Barbarini

Volume 19, Issue 6, 2023

Published on: 16 September, 2022

Article ID: e230822207921 Pages: 4

DOI: 10.2174/1573405618666220823122813

Price: $65

conference banner
Abstract

Background: Internuclear ophthalmoplegia (INO) is a disorder of eye movements caused by a lesion involving the medial longitudinal fasciculus (MLF) within the brainstem, and it is characterized by adduction impairment combined with contralateral dissociated abduction nystagmus. The frequency of acute ischemic stroke (AIS) presenting with INO as a predominant symptom is very low, and many patients suffering from this brainstem AIS are precluded from intravenous thrombolysis (IVT).

Objective: To provide for the first time a magnetic resonance imaging (MRI) evidence of response to the IVT in brainstem wake-up stroke presenting with INO as an isolated symptom.

Methods: Here, we described a rare case of pons AIS presenting with INO as a unique symptom of awakening. In order to differentiate an ischemic stroke from other stroke mimics, and to determine whether the patient was within the therapeutic window for IVT (wake-up stroke), brain MRI including DWI and FLAIR sequences was acquired.

Results: A left paramedian pontine DWI/FLAIR mismatch was detected and the patient was considered eligible for IVT. After IVT, the patient made a full recovery with complete resolution of INO. Follow-up MRI at 1 month demonstrates the absence of ischemic lesions.

Conclusion: Our case provides neuroradiological evidence of IVT efficacy in brainstem stroke, and it should prompt clinicians to rapidly perform MRI in wake-up onset INO and to just as quickly administer IVT, since INO is a functionally disabling deficit. Finally, this case demonstrates the value of MRI in diagnostic, prognostic, and therapeutic workup of posterior circulation wake-up stroke.

Keywords: Internuclear Ophthalmoplegia (INO), brainstem wake-up stroke, magnetic resonance imaging (MRI), diffusion weighted imaging/fluid attenuated inversion recovery (DWI/FLAIR) mismatch, intravenous thrombolysis (IVT).

Graphical Abstract
[1]
Smith JL, Cogan DG. Internuclear ophthalmoplegia. AMA Arch Opthalmol 1959; 61(5): 687-94.
[http://dx.doi.org/10.1001/archopht.1959.00940090689003] [PMID: 13636562]
[2]
Kim JS. Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction. Neurology 2004; 62(9): 1491-6.
[http://dx.doi.org/10.1212/01.WNL.0000123093.37069.6D] [PMID: 15136670]
[3]
Kranz PG, Eastwood JD. Does diffusion-weighted imaging represent the ischemic core? An evidence-based systematic review. AJNR Am J Neuroradiol 2009; 30(6): 1206-12.
[http://dx.doi.org/10.3174/ajnr.A1547] [PMID: 19357385]
[4]
Latchaw RE, Alberts MJ, Lev MH, et al. Recommendations for imaging of acute ischemic stroke: A scientific statement from the American Heart Association. Stroke 2009; 40(11): 3646-78.
[http://dx.doi.org/10.1161/STROKEAHA.108.192616] [PMID: 19797189]
[5]
Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute stroke. West J Emerg Med 2011; 12(1): 67-76.
[PMID: 21694755]
[6]
Thomalla G, Cheng B, Ebinger M, et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): A multicentre observational study. Lancet Neurol 2011; 10(11): 978-86.
[http://dx.doi.org/10.1016/S1474-4422(11)70192-2] [PMID: 21978972]
[7]
Awerbuch G, Brown M, Levin JR. Magnetic resonance imaging correlates of internuclear ophthalmoplegia. Int J Neurosci 1990; 52(1-2): 39-43.
[http://dx.doi.org/10.3109/00207459008994242] [PMID: 2265923]
[8]
Kleinsorge MT, Ebert A, Förster A, et al. MRI topography of lesions related to internuclear ophthalmoplegia in patients with multiple sclerosis or ischemic stroke. J Neuroimaging 2021; 31(3): 471-4.
[http://dx.doi.org/10.1111/jon.12847] [PMID: 33793026]
[9]
Figueiredo C, Fernandes M, Casimiro C, Santos M, Costa C. Internuclear ophthalmoplegia as an atypical presentation of lacunar stroke in CADASIL. J Thromb Thrombolysis 2021; 52(1): 350-3.
[http://dx.doi.org/10.1007/s11239-020-02359-2] [PMID: 33387205]
[10]
Jiang Z, Wang W. Isolated bilateral internuclear ophthalmoplegia due to lacunar infarction. Neurol Sci 2018; 39(4): 795-6.
[http://dx.doi.org/10.1007/s10072-017-3199-8] [PMID: 29170848]
[11]
Mahawish KM, Aravind A. Acute onset internuclear ophthalmoplegia responsive to treatment with intravenous alteplase. N Z Med J 2020; 133(1515): 119-21.
[PMID: 32438384]

Rights & Permissions Print Cite
© 2024 Bentham Science Publishers | Privacy Policy