© 2005 BMJ Publishing Group Ltd
SHORT REPORT
Bilateral paramedian midbrain infarct: an uncommon variant of the "top of the basilar" syndrome
1 Department of Neurology, University of Athens, Athens, Greece
2 Department of Neurology, University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany
3 Department of Clinical Therapeutics, University of Athens, Athens, Greece
Correspondence to:
Correspondence to:
Dr K Spengos
Department of Neurology, University of Athens, Vas. Sofias 82, 11528 Athens, Greece; spengos{at}hol.gr
Occlusion of the rostral portion of the basilar artery can result in ischaemia of the midbrain and thalami, as well as of the temporal and occipital lobes. The so called "top of the basilar" syndrome manifests clinically as numerous combinations of abnormalities of alertness, sleep–wake cycle, and behaviour and oculomotor or pupillomotor functions. A 67 year old man presented with bilateral internuclear ophthalmoplegia, rubral tremor, and daytime somnolence. He was awake during the night and mostly agitated and aggressive. An ischaemic lesion was visible on the magnetic resonance (MR) image in the central portion of the midbrain just ventral to the aqueduct, clearly affecting the paramedian structures bilaterally. MR angiographic images demonstrated a hypoplastic basilar artery ending in both superior cerebellar arteries. Both posterior cerebral arteries were seen to arise from the corresponding internal carotid arteries via the posterior communicating branches. This unique case of an acute bilateral paramedian infarct represents a highly uncommon variant of the "top of the basilar" syndrome and was due to the affected ischaemic territory—that is, the "distal field" of the variant basilar artery.
Abbreviations: INO, internuclear ophthalmoplegia; PCA, posterior cerebral artery
Keywords: bilateral internuclear ophthalmoplegia; bilateral paramedian midbrain infarct; rubral tremor; "top of the basilar" syndrome
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Brain stem / cerebellum
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Cranial nerves
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Drugs: CNS (not psychiatric)
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Sleep disorders (neurology)
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Ophthalmology
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