Millard-Gubler Syndrome Associated with Cerebellar Ataxia in a Patient with Isolated Paramedian Pontine Infarction – A Rarely Observed Combination with a Benign Prognosis: A Case Report

Abstract

Isolated pontine infarction accounts for 7% of all ischemic strokes. Millard-Gubler syndrome is a clinical syndrome which occurs following lesions involving the ventral portion of the caudal pons, resulting in classic clinical features such as ipsilateral abducens and facial nerve palsy and contralateral hemiparesis. We report the case of a 55-year-old male patient having presented to the Yehuleshet Specialty Clinic 6 years back with sudden-onset dysarthria and appendicular ataxia of 10 days duration. He reported having right hemibody weakness and blurred vision, which have significantly improved since then. He had a history of smoking of 30 pack-years. However, he quit smoking 8 years ago. There was no history of prior stroke, transient ischemic attack, diabetes, hypertension, head trauma, or dyslipidemia. On examination, he had horizontal left gaze palsy with horizontal nystagmus suggesting left-sided 6th cranial nerve palsy. He had mild left-sided facial palsy causing dysarthric speech. Right upper limb dysmetria was observed during examination; otherwise, motor, sensory, fundus, and gait examination results were normal. He had low serum vitamin D. Brain magnetic resonance imaging examination showed a 25 × 10 mm segmental lesion in the left median pons involving the basis pontis and tegmentum section. The lesion had T2 and T1 abnormal prolongation with no diffusion restriction, suggesting a subacute pontine infarct. The patient was managed with aspirin 325 mg, atorvastatin 80 mg, physical therapy, and vitamin D supplementation, and advised on behavioral risk factors. Six years after his isolated pontine infarction, the patient is fully recovered from dysarthria, facial palsy, hemiparesis, right-sided appendicular ataxia, and horizontal nystagmus, and the follow-up brain MRI showed radiological evidence of chronic paramedian pontine perforator infarction. Millard-Gubler syndrome may present with cerebellar ataxia if the paramedian pontine infarction area slightly extends laterally, affecting the middle cerebellar peduncles. Isolated pontine infarction may have a good prognosis if diagnosed and managed early.

Pontine Infarct Resulting in Millard-Gubler Syndrome: A Case Report

“…Our patient had a full recovery within one week of presentation. This is consistent with the clinical course described in case reports, especially those involving small acute infarcts [2,4,6,7,9,10].…”

“…The involvement of the pyramidal tracts usually manifests in hemiplegia or hemiparesis of upper or lower extremities in addition to facial palsy [2][3][4][5]10]. In our case, there was no motor deficit in the extremities.…”

“…Millard-Gubler syndrome, also known as ventral pontine syndrome or facial abducens hemiplegia syndrome, was first described in 1858, and was classically associated with a pontine mass [8]. Subsequent reports, however, have involved cases caused by bleeding and infarcts, and rarely neurocysticercosis [2][3][4][5][6][7]9,10]. The lesion lies above the level of the decussation of the pyramidal and spinothalamic tracts.…”

Neurology Training and Medical Education in Resource-Limited Settings: Building and Growing the First Neurology Residency Program in East Africa

“…Between 2021 and 2023, a total of 61 manuscripts were authored by our alumni, including 27 original research articles, 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 16 case reports, 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 2 perspective pieces, 50 51 3 review articles, 52 53 54 1 book chapter, 55 1 association statement, 56 1 consensus statement, 57 1 data note, 58 and 8 that were published on a preprint server (not peer reviewed). 59 60 61 62 63 64 65 Of these academic contributions, 19 of these papers were published in journals with an impact factor of 3.0 to 10.0.…”

A Rare Neurological Sequela: Pontine Infarct Conducing to Millard-gubler Syndrome

“…This is a charming ventral pontine problem that shows up with the ipsilateral deficiency of the eye upon snatching (abducens nerve), ipsilateral facial muscle inadequacy (facial nerve), and contralateral hemiparesis or hemiplegia of the upper and lower limbs (pyramidal nerve strands) [4][5][6]. This is generally a direct result of an uneven lesion at the basal part of the caudal pons due to a tumor, hemorrhage, or sometimes, infarction [7][8][9][10]. Hemorrhage and localized necrosis are more typical in seasoned patients, while tissue development and illnesses are more ordinary in additional young individuals.…”