Millar Gubler syndrome includes the following except (AIIMS May 2011)
|A||5th nerve palsy|
|B||6th nerve palsy|
|C||7th nerve palsy|
5th nerve palsy
1). Ventral pontine syndrome (Millard Gubler syndrome)
Caused by paramedian infarction of pons
a. Ipsilateral paresis of lateral rectus with diplopia (damage to abducent fasciculus / nucleus spared)
b. Ipsilateral paresis of upper and lower face (damage to 7th cranial nerve)
c. Contralateral hemiplegia with sparing of contralateral face (damage to corticospinal tract)
2). Lower dorsal pontine syndrome (Foville's syndrome)
Caused by lesion in dorsal tegmentum of lower pons
a. Ipsilateral horizontal gaze palsy (damage to nucleus of abducent nerve and paramedian pontine reticular formation.)
b. Ipsilateral paresis of whole face (damage to nucleus and fibers of 7th nerve)
c. Contralateral hemiplegia with sparing of Contralateral face (damage to corticospinal tract)
3). Upper dorsal pontine syndrome (Raymond Ceston syndrome)
Caused by obstruction of long circumferential branches of basilar artery
a. Ipsilateral ataxia and coarse intention tremor (damage to superior and middle cerebellar peduncle)
b. Ipsilateral paralysis of muscles of mastication and sensory loss in face. (damage to sensory and motor nuclei and tracts of CNV)
c. Contralateral loss of sensory modalities in the body (damage to spinothalamic tract and medial lemniscus)
d. Contralateral hemiparesis of face and body (damage to corticospinal tract) may occur with ventral extension of lesion.
e. Horizontal gaze palsy may occur (as in lower dorsal pontine syndrome)
Locked – In – syndrome: Bilateral ventral pontine lesion
Able to communicate only by vertical eye movement and blinking but otherwise is completely immobile)
1). Occurs in patients will bilateral ventral pontine lesion
2). Its most common cause is pontine infarction.
3). Patient has following features:
a. Is quadriplegic (bilateral damage to corticospinal tract in ventral pons
b. Is unable to speak and incapable of facial movements (involvement of corticobulbar tracts)
c. Has limited Horizontal eye movements (bilateral involvement of nuclei and fibres of 6th CN)
d. Has intact vertical eye movements and blinking (supranuclear ocular motor pathways are spared)
e. Has preserved consciousness (reticular formation is not damaged)
Extra Edge: Locked-in syndrome (Ref: Harrison, 18th, Pg- 2247)
1). Locked-in syndrome is a condition in which a patient is aware and awake but cannot move or communicate verbally due to complete paralysis of nearly all voluntary muscles in the body except for the eyes.
2). Total locked-in syndrome is a version of locked-in syndrome where the eyes are paralyzed as well. It is the result of a brain stem lesion in which the ventral (anterior) part of the pons is damaged.
3). Locked-in syndrome is also known as cerebromedullospinal disconnection, de-efferented state, pseudocoma, and ventral pontine syndrome.
Lesion affecting VI nerve
Site Clinical features
Pons Millard – Gubler syndrome = ipsilateral VI, VII palsy + C/L hemiparesis
Foville’s syndrome = lat. gaze palsy, ipsilateral VI, VII, palsy, C/L hemiparesis
Extra Edge: (Ref. Hari- 18th ed., pg- 3434)
1). Headache and earache are the most frequent symptoms of transverse sinus thrombosis.
2. A transverse sinus thrombosis may also present with otitis media, sixth nerve palsy, and retroorbital or facial pain (Gradenigo's syndrome).
3). Sigmoid sinus and internal jugular vein thrombosis may present with neck pain.