Pediatric Neurology 52 (2015) 466e467
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Visual Diagnosis
Internuclear Opthalmoplegia as a Symptom of Ischemic Stroke in a Girl With Patent Foramen Ovale ska MD PhD *, Marta Szmuda MD PhD, Maria Mazurkiewicz-Bełdzin Marta Zawadzka MD sk, Gdan sk, Poland Department of Developmental Neurology, Medical University of Gdan
A previously healthy 16-year-old girl presented with sudden-onset diplopia and dizziness. Both symptoms appeared on the day of admission, soon after awakening in
the morning. The day before admission, she complained of a headache followed by transient numbness in the right half of her face. Neurological examination revealed an internu-
FIGURE. (A) Forward gaze. (B) Upward gaze. (C) Limited adduction in the left eye with a horizontal nystagmus in the right eye while attempting a right gaze. (D) Left lateral gaze. (E,F) Magnetic resonance imaging T2-weighted images showing a hyperintense focus on the left side of the midbrain at the level of quadrigeminal lamina. (G) Magnetic resonance imaging diffusion-weighted image showing a high signal on the left side of the midbrain. (H) Apparent diffusion coefficient map with a low signal on the left side of the midbrain. (The color version of this figure is available in the online edition.) * Communications should be addressed to: Maria Mazurkiewicz-Bełd ska; Department of Developmental Neurology; Chair of Neurology; zin sk; ul. De˛ binki 7, 80-952 Gdansk, Poland. Medical University of Gdan E-mail address: [email protected] 0887-8994/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.12.007
clear ophthalmoplegia (limited adduction in the left eye with a horizontal nystagmus in the right eye during attempted right gaze, Figure A-D).
ska et al. / Pediatric Neurology 52 (2015) 466e467 M. Mazurkiewicz-Bełdzin
Magnetic resonance imaging (MRI) diffusion-weighted images revealed a high signal lesion of the left midbrain at the level of quadrigeminal lamina (Figure E,F). A corresponding low signal was observed on the apparent diffusion coefficient map. The lesion did not enhance following gadolinium. The MRI findings and clinical data indicated midbrain ischemia as the cause of the symptoms. Laboratory tests did not detect any disorders of coagulation nor any markers of systemic autoimmune diseases. Transthoracic echocardiography revealed a right-to-left shunt and transesophageal echocardiography confirmed the presence of patent foramen ovale (PFO). She was treated with antiplatelet therapy (aspirin) and her neurological deficits completely resolved within two weeks. Five weeks after discharge, she underwent transcatheter closure of the PFO via a transfemoral approach. MRI performed six months later confirmed resolution of the ischemic lesions. Currently, she has no complaints other than occasional headaches. Discussion
Internuclear opthalmoplegia results from a lesion in the medial longitudinal fasciculus.1 This is a rare eye movement
467
disorder in the pediatric population.2 The most common causes of internuclear opthalmoplegia are multiple sclerosis and brainstem ischemia. Other causes include trauma, tumors, and neuroinfections.3 The prevalence of PFO decreases with age, with a peak in the first three decades. Our patient had no diagnostic abnormalities except for the PFO on echocardiography and ischemic lesions in MRI. It seems plausible that the stroke was caused by a paradoxical embolism resulting from right-to-left shunting. The transient sensory disturbances were probably the result of an embolic transient ischemic attack. Stroke is a rare cause of internuclear opthalmoplegia but nevertheless needs to be considered when diagnosing this condition in the pediatric population. References 1. Erkilic, Ozkiris A, Evereklioglu C, et al. Internuclear opthalmoplegia as a symptom associated with Henoch-Schoenlein purpura. Neuroopthalmol. 2001;26:193-196. 2. Rizzo JL, Lloyd M, O’Hara MA. Pediatric internuclear ophthalmoplegia. J Neuro-ophthalmol. 2013;33:134-136. 3. Bolanos J, Lozano D, Cantu C. Internuclear ophthalmoplegia: causes and long-term follow up in 65 patients. Acta Neurol Scand. 2004;110: 161-165.
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Visual Diagnosis
Internuclear Opthalmoplegia as a Symptom of Ischemic Stroke in a Girl With Patent Foramen Ovale ska MD PhD *, Marta Szmuda MD PhD, Maria Mazurkiewicz-Bełdzin Marta Zawadzka MD sk, Gdan sk, Poland Department of Developmental Neurology, Medical University of Gdan
A previously healthy 16-year-old girl presented with sudden-onset diplopia and dizziness. Both symptoms appeared on the day of admission, soon after awakening in
the morning. The day before admission, she complained of a headache followed by transient numbness in the right half of her face. Neurological examination revealed an internu-
FIGURE. (A) Forward gaze. (B) Upward gaze. (C) Limited adduction in the left eye with a horizontal nystagmus in the right eye while attempting a right gaze. (D) Left lateral gaze. (E,F) Magnetic resonance imaging T2-weighted images showing a hyperintense focus on the left side of the midbrain at the level of quadrigeminal lamina. (G) Magnetic resonance imaging diffusion-weighted image showing a high signal on the left side of the midbrain. (H) Apparent diffusion coefficient map with a low signal on the left side of the midbrain. (The color version of this figure is available in the online edition.) * Communications should be addressed to: Maria Mazurkiewicz-Bełd ska; Department of Developmental Neurology; Chair of Neurology; zin sk; ul. De˛ binki 7, 80-952 Gdansk, Poland. Medical University of Gdan E-mail address: [email protected] 0887-8994/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.12.007
clear ophthalmoplegia (limited adduction in the left eye with a horizontal nystagmus in the right eye during attempted right gaze, Figure A-D).
ska et al. / Pediatric Neurology 52 (2015) 466e467 M. Mazurkiewicz-Bełdzin
Magnetic resonance imaging (MRI) diffusion-weighted images revealed a high signal lesion of the left midbrain at the level of quadrigeminal lamina (Figure E,F). A corresponding low signal was observed on the apparent diffusion coefficient map. The lesion did not enhance following gadolinium. The MRI findings and clinical data indicated midbrain ischemia as the cause of the symptoms. Laboratory tests did not detect any disorders of coagulation nor any markers of systemic autoimmune diseases. Transthoracic echocardiography revealed a right-to-left shunt and transesophageal echocardiography confirmed the presence of patent foramen ovale (PFO). She was treated with antiplatelet therapy (aspirin) and her neurological deficits completely resolved within two weeks. Five weeks after discharge, she underwent transcatheter closure of the PFO via a transfemoral approach. MRI performed six months later confirmed resolution of the ischemic lesions. Currently, she has no complaints other than occasional headaches. Discussion
Internuclear opthalmoplegia results from a lesion in the medial longitudinal fasciculus.1 This is a rare eye movement
467
disorder in the pediatric population.2 The most common causes of internuclear opthalmoplegia are multiple sclerosis and brainstem ischemia. Other causes include trauma, tumors, and neuroinfections.3 The prevalence of PFO decreases with age, with a peak in the first three decades. Our patient had no diagnostic abnormalities except for the PFO on echocardiography and ischemic lesions in MRI. It seems plausible that the stroke was caused by a paradoxical embolism resulting from right-to-left shunting. The transient sensory disturbances were probably the result of an embolic transient ischemic attack. Stroke is a rare cause of internuclear opthalmoplegia but nevertheless needs to be considered when diagnosing this condition in the pediatric population. References 1. Erkilic, Ozkiris A, Evereklioglu C, et al. Internuclear opthalmoplegia as a symptom associated with Henoch-Schoenlein purpura. Neuroopthalmol. 2001;26:193-196. 2. Rizzo JL, Lloyd M, O’Hara MA. Pediatric internuclear ophthalmoplegia. J Neuro-ophthalmol. 2013;33:134-136. 3. Bolanos J, Lozano D, Cantu C. Internuclear ophthalmoplegia: causes and long-term follow up in 65 patients. Acta Neurol Scand. 2004;110: 161-165.
