A case of one and a half syndrome

Cranial nerve examination

CN1
-

Smell normal

CN2, 3, 4, 6
-

ph VA 0.5/0.6
Pupils: both sides less reactive, left worse than right; no RAPD;
accommodation intact
VF by confrontation: normal
EOM: primary gaze straight, horizontal diplopia on primary gaze and all
positions; upward gaze preserved

Fundi: bilateral blurred disc margins

CN5
-

Muscles of mastication: temporalis, masseter, lateral pterygoid normal

Sensation: V1, V2, V3 intact
Corneal reflex: skipped
Jaw jerk: skipped

CN7
-

Frontalis: less prominent creases on right side

Orbicularis oculi: weaker on right side
Buccinator: cant tell the difference
Showing teeth: dropping of right angle of jaw
Platysmus: cant tell the difference

CN8
-

Cochlear nerve: Hearing normal

Vesticular nerve: May have some dizziness?? from the history

CN9, 10
-

Uvula: midline
Gag reflex: preserved

CN11
-

SCM: normal
Trapezius: normal

CN12
-

Tongue: no fasciculation or wasting, no deviation, power normal

UL&LL examination
Inspection
-

Nothing special

Tone
-

Normal

Power
5 4
5 4

Reflexes
-

Not done

Sensation
-

Decreased pin prick sensation of left UL&LL

Light touch: skipped
Temperature: skipped
Proprioception: skipped
Vibration: skipped

Cerebellar sign
-

Finger-nose test: left past-pointing and intention tremor, right normal

Repetitive alternating movement: left dysdiadochokinesia
Rebound: not done
Heel-shin test: positive on the left, normal on the right
Other cerebellar signs: skipped

Gait
-

Could only stand with support due to weakness

Where is the lesion?

Bilateral pupils less
reactive to light
Bilateral papilloedema
Right one and a half
syndrome
Right LMN type CN7
palsy
Dizziness?? from history

PapilloedemaCN2
dysfunction? or
Bilateral CN3 nucleus
Sign of increased ICP
Right MLF, CN6
nucleus, PPRF
Right CN7 nucleus
Right CN8 nucleus

Left hemiplegia

Right corticospinal
tract
most likely

Left decreased pinprick sensation

Right lateral
spinothalamic tract
most likely

Left cerebellar signs

Left cerebellar peduncle

or
Left cerebellum

Bilateral CN2?
Bilateral midbrain?
Intracranial
Right medial pons
Right medial pons or
below
Right lateral pons or
below
Right medial
brainstem above
decussation at
medulla
Left medial brainstem
below decussation at
medulla
Right lateral
brainstem up to
thalamus and down to
right spinal cord
Left pons or
Left cerebellum

Summary
This patient has right one and a half syndrome, right LMN type CN7 palsy, left
hemiplegia and left decreased pin-prick sensation suggestive of a lesion in the
right pons. She also has bilateral papilloedema suggestive of increased ICP.

Case History
F/33, Fok
PMH: Known 3 cm pontine AVM
HPI:
Admitted to RH for dizziness and increased left numbness. Vomit x 1. Slurred
speech. No headache/trauma.
CT brain: 18-20 mm brainstem haematoma with intraventricular extension
Transferred to QMH: right CN7 palsy, left hemiplegia, failed right gaze
Urgent OT with EVD done