Teaching Video NeuroImages: From 9 to 8-and-a-Half Syndrome After tPA: The Rebirth of Fellini

A 73-year-old woman presented with acute impaired eye movements with preserved left eye abduction, right peripheral facial weakness (video 1), and left hemiparesis/hemihypesthesia. These deficits localized to the right pontine tegmentum involving the medial longitudinal fasciculus, facial nerve, abducens nucleus, medial lemniscus, and corticospinal tracts, as shown in figure 1. After tissue plasminogen activator, her left hemiparesis and hemihypesthesia resolved. Rosini et al.1 first described these deficits as 9 syndrome (7th nerve + 1.5 syndrome + 0.5 hemiparesis/hypesthesia = 9). Classically, 1-and-a-half syndrome consists of intranuclear ophthalmoplegia and conjugate horizontal gaze palsy; preserved abduction will be present in the contralateral eye. Our patient’s right eye adduction was paretic and not plegic. Our patient was left with an “8-and-a-half syndrome” (figure 2). Infarct, hemorrhage, vasculitis, and demyelination are etiologies of 8-and-a-half syndromes reported in the literature.

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