Bilateral, vertical supranuclear gaze palsy following unilateral midbrain infarct

BMJ Case Rep. 2020 Nov 4;13(11):e238422. doi: 10.1136/bcr-2020-238422.

Abstract

A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation.

Keywords: TB and other respiratory infections; contraindications and precautions; neuroopthalmology; stroke; visual pathway.

Publication types

  • Case Reports

MeSH terms

  • Aspirin / administration & dosage*
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Betacoronavirus / isolation & purification
  • Blindness* / diagnosis
  • Blindness* / etiology
  • Brain Stem Infarctions* / diagnostic imaging
  • Brain Stem Infarctions* / drug therapy
  • Brain Stem Infarctions* / physiopathology
  • COVID-19
  • Coronavirus Infections* / complications
  • Coronavirus Infections* / diagnosis
  • Coronavirus Infections* / physiopathology
  • Diplopia* / diagnosis
  • Diplopia* / etiology
  • Endocarditis, Bacterial* / complications
  • Endocarditis, Bacterial* / diagnosis
  • Endocarditis, Bacterial* / physiopathology
  • Factor Xa Inhibitors / administration & dosage
  • Humans
  • Magnetic Resonance Imaging / methods
  • Male
  • Middle Aged
  • Ophthalmoplegia* / diagnosis
  • Ophthalmoplegia* / etiology
  • Pandemics*
  • Platelet Aggregation Inhibitors / administration & dosage
  • Pneumonia, Viral* / complications
  • Pneumonia, Viral* / diagnosis
  • Pneumonia, Viral* / physiopathology
  • Pyrazoles / administration & dosage*
  • Pyridones / administration & dosage*
  • Retinal Artery Occlusion* / diagnostic imaging
  • Retinal Artery Occlusion* / drug therapy
  • Retinal Artery Occlusion* / etiology
  • Retinal Artery Occlusion* / physiopathology
  • SARS-CoV-2
  • Tomography, Optical Coherence / methods
  • Treatment Outcome

Substances

  • Factor Xa Inhibitors
  • Platelet Aggregation Inhibitors
  • Pyrazoles
  • Pyridones
  • apixaban
  • Aspirin