Unilateral asterixis, thalamic astasia and vertical one and half syndrome in a unilateral posterior thalamo-subthalamic paramedian infarct: An interesting case report
A 42-year-old young lady presented with 3 days history of acute onset of dizziness, transient loss of consciousness, sudden drooping of left eyelid and binocular diplopia with difficulty in walking unassisted. She also had hypersomnolescence. There was history of hypertension and uncontrolled diabetes mellitus of 2 years duration. Her admission BP was 210/120 mm hg and her blood sugar was 283 mg/dl with urine acetone positive at admission. She had past history of migraine for several years. Systemic examination was normal. Higher mental functions were normal. She had complete ptosis with dilated 5 mm nonreactive pupil on left side. There was left internuclear ophthalmoplegia and skew deviation with left hypertropia. There was also bilateral up gaze palsy with monocular left down gaze palsy and the only possible vertical movement was downward movement of right eye suggestive of vertical one and half syndrome. There was bilateral horizontal gaze evoked nystagmus. Convergence was impaired. Bell's phenomenon and vertical oculocephalic movement was absent. The muscle strength, sensory system, finger nose and knee heel coordination were normal. Reflexes were normal and plantars flexors. She was not able to sit or stand without support. She had thalamic astasia, was leaning back while sitting and required support to walk. On outstretched prone arm, dorsiflexed wrist, she had right asterixis which comprised of semi rhythmic flexion movements at wrist and fingers.\nOn evaluation, biochemistry, lipid profile and blood counts were normal. Cardiac evaluation was normal. MRI imaging showed evidence of T1 hypo intense and T2, Flair hyper intense signal changes in left anterior thalamus, subthalamus, left midbrain including periaqueductal region []. There were also bilateral frontal caps, bilateral asymmetric fronto parietal sub cortical white matter and symmetric peritrigonal white matter signal changes. Magnetic Resonance angiogram was normal and diffusion studies showed restriction [Figures and ]. There were no hemorrhage or micro bleeds. Patient was started on anti-platelets, anti-edema measures, antihypertensive and insulin. Ptosis, diplopia, dizziness and ataxia started improving gradually over next 2 days.