You are rotating on the neurology service and are asked to see a 66-year-old
man who presents with the suddent onset of "difficulty with my eyes". Your attending
does several tests involving movement of the patient's head (see below).
What is your diagnosis, what test or tests would you order to confirm your suspicions,
and what treatment, if any, do you recommend?
DIAGNOSIS: Horizontal supranuclear palsy. Horizontal gaze palsy can result from a
supranuclear lesion in the frontal premotor area of the contralateral hemisphere or
in the horizontal gaze center in the pons. In this patient, on Doll's head rotation
to the left, the eyes deviate fully to the right demonstrating intact pontine reflexes
and the supranuclear nature of the lesion. The cause in this patient was a large infarct
of the internal capsule due to occlusion of branches of the left middle cerebral artery
(see below).
A. B. C.
The patient can look to left (A) but not to the right (B) and has a normal Doll's
Eye manuveur (C) indictating the supranuclear nature of the lesion.
Infarction of the left internal capsule (CT scan, left image). Horizontal gaze pathways (illustration, right image).
.