[Difficulty in eye opening following left hemispheric infarction-- causative lesion and pathophysiology of abnormalities of the eye and eyelids movements].
We reported a patient suffering from difficulty in eye opening following left hemispheric infarction. A 78-year-old left-handed woman with atrial fibrillation had an acute onset of right hemiparesis and difficulty in eye opening. On admission, mild disorientation, vertical gaze palsy, right homonymous hemianopia, anosognosia of right hemiparesis, agnosia of right side of the body and forced grasping reflex of the left hand were seen. She was aware of her difficulty in opening her eyelids. Vertical saccadic eye movements were absent to command but when her head was free to move, the vertical saccadic eye movements improved that may suggest oculomotor apraxia. Bell's phenomenon was absent, and optokinetic responses were normal. Aphasia and facial apraxia were not seen. Brain CT and MRI demonstrated infarction in the territory of the anterior divisions of the left middle cerebral artery which includes the inferior frontal gyrus, middle frontal gyrus, fronto-parietal operculum and temporal operculum. SPECT disclosed hypoperfusion area in the left frontal lobe. No lesion was seen in the midbrain and pons. On the basis of these findings, cerebral emboli of the divisions of the left middle cerebral artery were diagnosed. Until about 11th days from onset, she could not open her eyelids by our verbal commands or even voluntarily, and showed paradoxical contraction of the bilateral orbicularis oculi muscles by verbal commands to open her eyes or when her eyes were forcedly opened by hands. After the 12th days from the onset, she became to be able to open her eyes voluntarily when she was asked to count the number of fingers presented in front of her face and when her families called her, but she could not open her eyes by verbal commands, which may be characteristic of apraxia of eyelid opening. She also had bilateral blephaloptosis when she opened her eyes. Considering this case together with previous reports, embolic lesion of the left cerebral hemisphere including the frontal eye field area and its adjacent areas which may be involved in higher control of eye lid movements and supranuclear vertical gaze movements was thought to cause difficulties in eye opening and vertical gaze palsy.
Waragai
M
M
Department of Neurology, School of Medicine, Chiba University.
Shinotoh
H
H
Kaneko
M
M
Hattori
T
T
D000368:Aged; D001763:Blepharoptosis / Q000209:etiology*; D001764:Blepharospasm / Q000209:etiology*; D002544:Cerebral Infarction / Q000150:complications* / Q000175:diagnosis / Q000473:pathology; D005260:Female; D005625:Frontal Lobe / Q000473:pathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D015840:Oculomotor Nerve Diseases / Q000209:etiology*; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed