Two Rare Cases of Ophthalmoplegia in Patients with Supratentorial Brain Lesions

초록

Introduction: Ophthalmological abnormalities with other neurological sign(s) frequently follow the infratentorial brain lesion. But only few cases with supratentorial brain lesion inducing ophthalmoplegia have been reported. We recently experienced two rare cases with phthalmoplegia; the first one with unilateral 3rd CN palsy caused by thalamic infarction, and the other with bilateral 6th CN palsy followed by rupture of an aneurysm on anterior communicating artery (ACA). Case 1: A 67 year old man was admitted with sudden onset of left side weakness and dysarthria. MRI revealed acute infarction on right frontal, occipital lobe and thalamus. Neurologic examination showed left hemiplegia, dysarthria, ptosis and eyeball deviation to temporal side of right eye. Another strange feature was that he had abnormal sexually impulsive behaviors. We applied an eye patch over his right eye, and prescribed antipsychotics. After a few weeks, he recovered from ptosis, abnormal eyeball deviation and abnormal behaviors. Case 2: A 71 year old women was admitted with drowsiness and severe headache. Brain CT and cerebrovascular angiography revealed a ruptured aneurysm on ACA and SAH on both hemispheres. Neurointervention by coiling of ACA aneurysm was done at department of neurosurgery. On neurologic exam, light reflex was preserved but there were anomaly in eyeball movement. Both eyeballs were deviated medially and she couldn’t move her eyes laterally. Her eyeball deviation was slowly improved and 2 months later, her symptoms were nearly normalized. Discussion: In the 1st case, the 3rd CN palsy could be induced by thalamic infarction extending to underlying midbrain. Bizarre sexually impulsive behavior could have also been related to the paramedian thalamic lesion. On the other hand, palsies of the 6th CN with SAH could be developed by various causes like direct compression oof the cerebral aneurysm or clot, pontine artery vasospasm or increased ICP