Teaching Video NeuroImages: Vertical one-and-a-half syndrome

Abstract

A 51-year-old woman with history of hypertension presented with left-sided weakness and diplopia. Imaging revealed a large hemorrhagic infarct involving the right thalamus and rostral midbrain with intraventricular extension (figure). Neuro-ophthalmic examination demonstrated bilateral upgaze palsy with limitation of infraduction on the right (video 1), overcome with a doll s head maneuver (video 2). Bilateral lid retraction was present with markedly reduced convergence along with convergence-retraction nystagmus. Vertical one-and-a half syndrome is an uncommon presentation resulting from a unilateral thalamomesencephalic stroke with involvement of the rostral interstitial nucleus of the medial longitudinal fasciculus and posterior commissure1 and was accompanied here by dorsal midbrain syndrome.