Supranuclear ocular movements comprise chiefly vertical and horizontal movements; horizontal movements are controlled by the subcortical centres located mainly at the pontine level and vertical movements at the level of the rostral midbrain.1 2 The classic one and a half syndrome is produced by a unilateral pontine tegmental lesion that includes the paramedian pontine reticular formation and medial longitudinal fasciculus on the same side, and has been considered an important ocular sign in neurological diagnosis.1 3 4 Vertical, as distinct from horizontal, one and a half syndrome, has also been documented recently.1 2 5 6 We report on a patient with concurrent vertical and horizontal one and a half syndromes.

A 57 year old man was admitted to hospital with a sudden onset of dysarthria and loss of consciousness while playing golf. He had a history of aortic regurgitation and heart failure 8 years previously, and underwent aortic valve replacement 5 years previously, when he started to take oral antiplatelet and anticoagulant drugs. On admission, he was comatose, and his blood pressure was 140/76 mm Hg. He also had atrial fibrillation, Cheyne-Stokes respiration, bilateral miosis, and a positive Babinski's sign. Brain CT showed lesions suspected of being infarcts in the right medial thalamus …