Vertical gaze palsy is a recognized manifestation of midbrain lesions. It rarely is a consequence of unilateral thalamic infarction.
We report the case of a 48-year-old African-American woman who presented to our facility with vertical gaze palsy and evidence of left medial thalamic infarct on diffusion-weighted imaging without coexisting midbrain ischemia. The etiology of infarct was determined to be small vessel disease after extensive investigation.
This report suggests a possible role of the thalamus as a vertical gaze control center. Clinicoradiological studies are needed to further define the role of the thalamus in vertical gaze control.
Khan et al.: Unilateral thalamic infarction presenting as vertical gaze palsy: a case report. Journal of Medical Case Reports 2011 5:535. The mechanism of vertical gaze paresis with unilateral lesions is uncertain but we can speculate on the possibi- lity of decussation of the frontobulbar fibers in the med- ia l tha lamus , as suggested in a case ser ies of tha lam ic infarctions presenting as vertica l gaze palsies  . The neuroimaging study results from our patient revealed no m i db r a in l e s io n . T h e r e h a s b e en a p r e v io u s c a s e reported of transient vertical gaze palsy with resolution of symptoms within three hours, highlighting the role of the thalamus in vertical gaze . Conclusions The combination of vertical gaze paresis and skew devia- t ion , prev ious ly be l ieved to be po int ing to a bra instem lesion, may now be attributed to a broader spectrum of anatomical areas. However, more cases correlating MRI f ind ing s w i th c l in ica l p re sen ta t ion s a s a t temp ted by Weidauer et al. need to be studied in order to establish the role of the thalamus in vertical gaze as either a cross- roads or an actual control center . Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images . A copy o f the writ ten consent is available for review by the Editor-in-Chief of this journal. Authorsâ€™ contributions MK was involved in the diagnosis and treatment of our patient, and wrote the manuscript. CS was involved in the diagnosis of our patient and helped with revising the manuscript. PS was involved in the diagnosis and management of our patient and helped in revising the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 5 March 2011 Accepted: 31 October 2011 Published: 31 October 2011 References 1. Bogousslavsky J, Miklossy J, Deruaz JP, Regli F, Assal G: Unilateral left paramedian infarction of thalamus and midbrain: a clinico-pathological study. J Neurol Neurosurg Psychiatry 1986, 49:686-694. Castaigne P, Lhermitte F, Buge A, Escourolle R, Hauw JJ, Lyon-Caen O: Paramedian thalamic and midbrain infarct: clinical and neuropathological study. Ann Neurol 1981, 10:127-148. Gentilini M, De Renzi E, Crisi G: Bilateral paramedian thalamic artery infarcts: report of eight cases. J Neurol Neurosurg Psychiatry 1987, 50:900-909. van der Graaff MM, Vanneste JA, Davies GA: Unilateral thalamic infarction and vertical gaze palsy: cause or coincidence? J Neuroophthalmol 2000, 20:127-129. 2. 3. 4. 5. Margolin E, Hanifan D, Berger MK, Ahmad OR, Trobe JD, Gebarski SS: Skew deviation as the initial manifestation of left paramedian thalamic infarction. J Neuroophthalmol 2008, 28:283-286. 6. Meissner I, Sapir S, Kokmen E, Stein SD: The paramedian diencephalic 7. syndrome: a dynamic phenomenon. Stroke 1987, 18:380-385. Schlag J, Schlag-Rey M: Neurophysiology of eye movements. Adv Neurol 1992, 57:135-147.