A 55-year-old diabetic woman suddenly develops weakness of the left side of her face as well as of her right arm and leg. She also has diplopia on left lateral gaze. Where is the responsible lesion?
This patient has weakness of the left face and the contralateral (right) arm and leg, commonly called a crossed hemiplegia. Such crossed syndromes are characteristic of brainstem lesions. In this case, the lesion is an infarct localized to the left inferior pons caused by occlusion of a branch of the basilar artery. The infarct has damaged the left sixth and seventh cranial nerves or nuclei in the left pons with resultant diplopia on left lateral gaze and left facial weakness. Also damaged is the left descending corticospinal tract, proximal to its decussation in the medulla; this damage causes weakness in the right arm and leg. This classic presentation is called the Millard-Gubler syndrome. Hemispheric lesions cause motor and sensory loss all on the same side (contralateral to the lesion). A lesion in the median longitudinal fasciculus causes third and sixth cranial nerve dysfunction but not motor deficit of the face or body.
Right cerebral hemisphere
Left cerebral hemisphere
Right side of the brainstem
Left side of the brainstem
C.N.S.