Bilateral horizontal gaze paralysis-case series
Bansal P. Bilateral horizontal gaze paralysis-case series. Neurology 2019; 92(15).
Objective: Description of two cases with bilateral horizontal gaze palsy as first manifestation of multiple sclerosis. Background: Complete Bilateral horizontal gaze paralysis is a rare syndrome, etiology being infarction, inflammation/demyelination, hemorrhage (6), and metastasis. Design/Methods: 1. A 39 year old female presented with improving diplopia of 15 days duration. She was found to have complete bilateral horizontal gaze palsy unable to be overcome by Vestibulo-ocular reflex. Convergence and vertical eye movements were normal. MRI brain showed few periventricular lesions and hyperintensity in paramedian floor of 4 ventricle. 2. A 36 year old male presented with diplopia of 1 day duration and was found to have bilateral internuclear ophthalmoplegia by an Ophthalmologist. The MRI brain showed 3 small periventricular white matter lesions without a brainstem pathology. Within 5 days, he developed partial right and complete left horizontal gaze palsy and left LMN facial paralysis when seen in my clinic. Cerebral MRI acoustic protocol showed lesion in pontine tegmentum. Results: Both patients had clinically isolated syndrome and underwent lumbar puncture which was positive for high IgG index and >4 oligoclonal bands in CSF (unmatched), with negative aquaporin-4 antibody. Testing for MS mimickers were negative. They received high dose IV steroids followed by oral taper. The condition gradually improved in both patients, following a similar progression as at the onset: improvement first involved the adduction movements in both eyes, with persistence of bilateral abduction paresis for a few weeks, followed by complete recovery. Conclusions: 1. Bilateral damage to medial longitudinal fasciculus followed by subsequent lateral extension to abducens nerves, and left facial nerve fasciculus in second patient might explain the clinical findings. th 2. MRI brain with acoustic protocol might be more beneficial in localizing brainstem pathology in early stages. 3. Knowledge about this syndrome among neurologists and ophthalmologists would minimize unnecessary investigations, delay in diagnosis and treatment.