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Images in Neurology
July 2011

Unusual Third Nerve Synkinesis Due to Midbrain Injury

Author Affiliations

Author Affiliations: Departments of Neurology (Drs Taieb, Renard, Castelnovo, and Labauge) and Ophthalmology (Dr Jeanjean), Hôpital Caremeau, Centre Hospitalier Universitaire Nîmes, France.

Arch Neurol. 2011;68(7):948-949. doi:10.1001/archneurol.2011.140

A 40-year-old woman presented with coma after head injury. Computed tomographic imaging revealed a parenchymal midbrain hemorrhage. The patient regained consciousness with palsy of all vertical eye movements (ie, saccades, smooth pursuit, optokinetic and vestibulo-ocular reflexes, and Bell phenomenon), bilateral ptosis, and bilateral dilated and unreactive pupils associated with paralysis of the near-vision triad. Results of visual acuity and direct ophthalmoscopic testing were normal. Four months later, results of ocular motility testing showed persistent palsy of all vertical eye movements. Also, horizontal eye movements displayed, in both directions, palpebral fissure widening of the adducting eye associated with palpebral fissure narrowing of the abducting eye (consistent with bilateral symmetrical acquired third nerve synkinesis) without globe retraction (video). Results of forced duction testing were normal. Orbital magnetic resonance imaging results were normal (including absence of medial rectus muscle entrapment). Brain magnetic resonance imaging revealed a symmetrical paramedian brainstem lesion (Figure).

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