Medial longitudinal fasciculus syndrome as a result of pontine hemorrhage
Presentation
Internuclear ophthalmoplegia, left-sided ataxia, right-sided facial hemispasm. History of pontine hemorrhage.
Patient Data
MRI demonstrates a right pontine tegmentum hyperintense lesion on T2 and ADC sequences and hypointense on Т1, FLAIR, SWI, and DWI. SWI mIP reveals the spread of hemosiderin along the posterior pontine tegmentum (projection of medial longitudinal fasciculus) and forward. Moreover, there are multiple foci of punctate supratentorial microhemorrhages, predominantly but not exclusively lobar, and areas of periventricular and deep white matter FLAIR hyperintensities.
Case Discussion
The history of the patient's pontine hemorrhage, appropriate clinical presentation, and MRI changes confirm the medial longitudinal fasciculus involvement.
MRI changes in this patient are multifactoral and have some challenges. He has a history of long-lasting uncontrolled hypertension, so this fact would rather indicate chronic hypertensive encephalopathy. However, the distribution of the microhemorrhages is not typical (predominantly lobar) and is more characteristic of cerebral amyloid angiopathy. As for the pontine lesion, cerebral cavernous malformation may underlie, and if so, the aforementioned changes may point to multiple type IV cavernomas.
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