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Benedict Syndrome

Hemiplegia Eye Movement Syndrome

Benedict syndrome (BS), also termed paramedian midbrain syndrome, is a rare stroke manifestation involving a lesion of the tegmentum of the midbrain. Infarctions of the red nucleus, cerebral peduncle, oculomotor fascicles, and the lower oculomotor nucleus are most commonly observed. BS manifestation is normally a consequence of infarcted branches of the posterior cerebral artery. BS is closely related to Weber's syndrome and Claude's syndrome.


Presentation

Benedict syndrome (BS) is caused by a stroke in the midbrain and usually presents as an ipsilateral oculomotor nerve palsy with contralateral hemi-tremor. Most common symptoms in BS are impaired eye movements affecting only one eye, hemichorea, slow one-sided tremor in the limbs, contralateral ataxia, dilated unresponsive pupils, ptosis, diplopia, hyperactive tendon reflexes, adiadokokinesis, contralateral hyperaesthesia and contralateral hemiparesis [1] [2] [3]. BS manifests with symptoms reminiscent of Weber's syndrome (WS) and Claude's syndrome (CS). BS is more often associated with hemiataxia, i.e. incoordination of movements, while WS more often presents with paralysis symptoms. An identifying symptom for BS in comparison to CS is contralateral hemiparesis, which never occurs in CS. Patients with BS have a rhythmic tremor of the contralateral hand and foot, which intensifies as a consequence of emotional excitement and during voluntary movements. Tremor is always absent during sleep in BS patients [4] [5].

BS is caused by a lesion, i.e. an infarction, hemorrhage or a tumor in the tegmentum of the midbrain and cerebellum. Infarctions of the posterior cerebral artery are suspected to be conducive to BS in most reported cases. Tuberculosis can also cause BS. Disruptions in the third cranial nerve, the red nucleus, the corticospinal tracts, the brachium conjunctivum, and the superior cerebellar peduncle decussation are normally associated with BS manifestations [1].

Motor anomalies in BS patients include a loss in arm swing on the affected side while the patient walks, a permanently semi-flexed arm and uncoordinated walking steps. These steps are characterized by swinging legs and a quick foot drop [4].

Cognitive functions remain unaffected in BS patients [1] [6].

Falling
  • […] consists of irregularities in the rhythm, rate, and amplitude of voluntary movements voluntary movements become jerky and erratic – cerebellar gait disturbances involve disturbances in stance and gait see the gait disorders, drop attacks and frequent falls[lifeinthefastlane.com]
  • Zelyonaya Kareta (The Green Coach, 2015): Oleg Asadulin's drama focuses on a successful film director whose life suddenly falls apart. Pyat Zvyozd-Novokuznetskaya Thurs. to Wed. at 5:15 p.m.[themoscowtimes.com]
  • Wallenberg syndrome consists of a constellation of signs and symptoms including ipsilateral limb and gait ataxia with a tendency to fall to the ipsilateral side (body lateropulsion) due to involvement of the restiform body and inferior surface of the[neupsykey.com]
Rigor
  • Syndrome Site of lesion Weber (hemiparesis alternans oculomotoria) Benedikt Ipsilateral side Contralateral side Oculomotor palsy Hemiparesis Oculomotor palsy Hyperkinesis (athetosis,chorea) Rigor Disturbance of deep sensibility Named Brainstem Syndromes[docshare.tips]
Thrombosis
  • Magnetic resonance imaging (MRI) and computer tomography (CT) scans are the final step in the workup since these methods provide the best chance to exclude other ailments with similar symptoms, e.g. cavernous sinus thrombosis.[symptoma.com]
  • . - optic ataxia - psychic paralysis of fixation of gaze - ectopic pupils - somnolence - cortical blindness Subclavian Steal Syndrome thrombosis of left subclavian aa. proximal to vertebral a. blood shunted retrograde down the left verterbral a & into[cram.com]
  • Cavernous sinus thrombosis It causes manifestation of 3rd nerve palsy. However there are several other nerves can get involved.[explainmedicine.com]
  • Thrombosis of the proximal part of the subclavian artery (left) results in retrograde blood flow through the ipsilateral vertebral artery and into the left subclavian artery.[vertigoexercises.us]
  • Deep vein thrombosis and pulmonary embolism. Myocardial infarction. Prognosis This will depend on the extent of disease; however: Acute basilar artery occlusion has a very high mortality rate.[patient.info]
Hypertension
  • A patient history featuring a smoking habit, pronounced hypertension, prolonged untreated diabetes, hypercholesterolemia and a familial predisposition for stroke-related disorders are crucial parameters for the diagnosis.[symptoma.com]
  • Over-enthusiastic treatment of hypertension should be avoided. Treat hypertension if hypertensive emergency exists. Treat hypotension: Intravenous fluids to maintain intravascular volume with isotonic fluids.[patient.info]
  • Risk factors include diabetes mellitus, hypertensive vascular disease, and elevated serum lipids. Hence, these patients require a medical evaluation for vasculopathic risk factors.[aao.org]
  • Physician editor: Christopher Sankey, MD, FACP Deputy physician editor: Benjamin Galen, MD, ACP Member Case 1: Benedikt's syndrome By Kristy Webster, MD, and Ashley Weber, MD The patient A 75-year-old woman with hypertension and hyperlipidemia presented[acphospitalist.org]
  • Small vessel disease (diabetes, hypertension, hypercholesterolemia) is the usual cause proposed by radiologists.[dizziness-and-balance.com]
Erythema
Diplopia
  • Most common symptoms in BS are impaired eye movements affecting only one eye, hemichorea, slow one-sided tremor in the limbs, contralateral ataxia, dilated unresponsive pupils, ptosis, diplopia, hyperactive tendon reflexes, adiadokokinesis, contralateral[symptoma.com]
  • [email protected] A 53-year-old man was admitted with diplopia, right ptosis, left lid retraction, mild left sided weakness and involuntary movements. Neurological examination revealed plus-minus lid and Benedikt's syndromes together.[docshare.tips]
  • Structures Affected Corticobulbar and corticospinal tracts Occulomotor Nerve, Apparatus for Conjugate Gaze, MLF, Vestibular Apparatus Visual Cortex Cerebellum Tegmentum of Thalmi Basilar Artery Syndrome Signs Paralysis of bulbar and corticospinal paralysis Diplopia[quizlet.com]
  • LR; medial strabismus, horizontal diplopia Dorsal Midbrain (Parinaud's Syndrome) Causes; pinealoma or germinoma 1. Superior colliculus and pretectal area. Paralysis of upward & downward gaze, pupillary disturbances & absence of convergence 2.[cram.com]
  • Visual disturbance (oculomotor signs such as nystagmus, diplopia and pupillary changes). Visual field defects. Speech disturbance (for example, dysarthria and dysphonia). Sensory changes in the face and scalp. Ataxia.[patient.info]
Ptosis
  • Clinical examination should focus on obvious BS symptoms like ptosis, eye deviations, pupillary anomalies, contralateral hemiparesis, lack of voluntary motor coordination and tremors.[symptoma.com]
  • Defisit occulomotorius termasuk ptosis, strabismus divergen, dan dilatasi pupil. Red nucleus berkoordinasi dari jaras cerebelar thalamic ke cereberel pedunkel superior (brachium conjunctivum).[docshare.tips]
  • In both these cases, MRD1 and MRD2 are increased on the side opposite to the apparent ptosis. Careful examination of facial muscle strength and symmetry usually confirms the cause of the apparent ptosis in these cases.[emedicine.medscape.com]
  • The patient has a complete ptosis. The eye under the lid is depressed and abducted (down and out). The pupil is dilated and unreactive to light or accommodation.[mrcophth.com]
Strabismus
  • Defisit occulomotorius termasuk ptosis, strabismus divergen, dan dilatasi pupil. Red nucleus berkoordinasi dari jaras cerebelar thalamic ke cereberel pedunkel superior (brachium conjunctivum).[docshare.tips]
  • With the eyelids retracted the right eye had a dilated pupil and a lateral strabismus. On attempted lateral gaze to the left the right eye would not proceed across the midline.[lksom.temple.edu]
  • LR; medial strabismus, horizontal diplopia Dorsal Midbrain (Parinaud's Syndrome) Causes; pinealoma or germinoma 1. Superior colliculus and pretectal area. Paralysis of upward & downward gaze, pupillary disturbances & absence of convergence 2.[cram.com]
  • . • Lesions of the internal genu of the facial nerve cause: -Ipsilateral facial paralysis -Ipsilateral loss of the corneal reflex • Lesions of the abducent nucleus cause: -Lateral rectus paralysis -Medial (convergent) strabismus -Horizontal diplopia 20[de.slideshare.net]
Strabismus
  • Defisit occulomotorius termasuk ptosis, strabismus divergen, dan dilatasi pupil. Red nucleus berkoordinasi dari jaras cerebelar thalamic ke cereberel pedunkel superior (brachium conjunctivum).[docshare.tips]
  • With the eyelids retracted the right eye had a dilated pupil and a lateral strabismus. On attempted lateral gaze to the left the right eye would not proceed across the midline.[lksom.temple.edu]
  • LR; medial strabismus, horizontal diplopia Dorsal Midbrain (Parinaud's Syndrome) Causes; pinealoma or germinoma 1. Superior colliculus and pretectal area. Paralysis of upward & downward gaze, pupillary disturbances & absence of convergence 2.[cram.com]
  • . • Lesions of the internal genu of the facial nerve cause: -Ipsilateral facial paralysis -Ipsilateral loss of the corneal reflex • Lesions of the abducent nucleus cause: -Lateral rectus paralysis -Medial (convergent) strabismus -Horizontal diplopia 20[de.slideshare.net]
Hemianopsia
  • Ischemic infarction in the territory of the PCA is usually secondary to total occlusion of the vessel.2 The clinical features vary and may include pure hemianopsia,2 resemble middle cerebral artery occlusion,3 4 or be restricted to thalamic disturbances[docshare.tips]
  • CT scans taken 6 and 48 hours after the onset of a right homonymous hemianopsia, due to the embolization of the left posterior cerebral artery, are shown in Figure 27-2, A and B, respectively.[what-when-how.com]
  • Proximal PCA occlusion may simulate MCA occlusion when it causes hemiparesis, hemianopsia, hemispatial neglect, aphasia, and sensory loss or inattention [ 68 ]. “Cortical” signs are probably explained by thalamic involvement.[neupsykey.com]
Tremor
  • Patients with BS have a rhythmic tremor of the contralateral hand and foot, which intensifies as a consequence of emotional excitement and during voluntary movements. Tremor is always absent during sleep in BS patients.[symptoma.com]
  • Lesi di red nucleus menghasilkan deficit dalam berkoordinasi kontralateral (ataxia), dysmetria, dysdiadokokinesis, rubral tremor ( resting tremor kasar yang meningkat apabila bergerak), dan pseudoparkinson tremor.[docshare.tips]
  • “rubral tremor (The blue fibers being the sup.[medicowesome.com]
  • Signs and symptoms [ edit ] It is characterized by the presence of an oculomotor nerve (CN III) palsy and cerebellar ataxia including tremor and involuntary choreoathetotic movements.[en.wikipedia.org]
  • […] hyperkinesias (rubral tremor).[jnnp.bmj.com]
Tremor
  • Patients with BS have a rhythmic tremor of the contralateral hand and foot, which intensifies as a consequence of emotional excitement and during voluntary movements. Tremor is always absent during sleep in BS patients.[symptoma.com]
  • Lesi di red nucleus menghasilkan deficit dalam berkoordinasi kontralateral (ataxia), dysmetria, dysdiadokokinesis, rubral tremor ( resting tremor kasar yang meningkat apabila bergerak), dan pseudoparkinson tremor.[docshare.tips]
  • “rubral tremor (The blue fibers being the sup.[medicowesome.com]
  • Signs and symptoms [ edit ] It is characterized by the presence of an oculomotor nerve (CN III) palsy and cerebellar ataxia including tremor and involuntary choreoathetotic movements.[en.wikipedia.org]
  • […] hyperkinesias (rubral tremor).[jnnp.bmj.com]
Ataxia
  • Lesi di red nucleus menghasilkan deficit dalam berkoordinasi kontralateral (ataxia), dysmetria, dysdiadokokinesis, rubral tremor ( resting tremor kasar yang meningkat apabila bergerak), dan pseudoparkinson tremor.[docshare.tips]
  • Most common symptoms in BS are impaired eye movements affecting only one eye, hemichorea, slow one-sided tremor in the limbs, contralateral ataxia, dilated unresponsive pupils, ptosis, diplopia, hyperactive tendon reflexes, adiadokokinesis, contralateral[symptoma.com]
  • Nothnagel's Syndrome mainly due to neoplasms ...affecting the Midbrain tectum involving Ipsilateral or bilateral CN 3 causes Oculomotor palsies; ataxia. We finish Alll the midbrain syndromes !!!!! Hope it helps! -Medha[medicowesome.com]
  • Midbrain: Paramedian Branches of PCA and Basilar Perforators (Ipsilateral) CN III Palsey (Contralateral) Weakness, vertical gaze palsey Midbrain: PCA occlusion - stroke of rednucleus and cerebral peduncle (Ipsilateral) CN III Palsey (Contralateral) Ataxia[quizlet.com]
  • Signs and symptoms [ edit ] It is characterized by the presence of an oculomotor nerve (CN III) palsy and cerebellar ataxia including tremor and involuntary choreoathetotic movements.[en.wikipedia.org]
Hemianesthesia
  • Corticospinal tract Facial and 6th palsy, contralateral Vascular,tumor hemiplegia, sometimes gaze palsy Avellis Medulla X tegmentum Paralysis of soft Spinothalamic, palate and vocal Infarct or sometimes cord and Tumor pupillary fibers contralateral hemianesthesia[docshare.tips]
  • Jackson Syndrome Cranial Nerves Paralysis of soft palate, vocal cord, contralateral hemianesthesia and ipsilateral tongue paralysis Lateral Tegmentum of Medulla Wallenberg Syndrome Cranial Nerves Spinal Tract V, IX, X, XI Wallenberg Syndrome Tracts Lateral[quizlet.com]
  • […] cord, pain and temp, analgesia, taste, Horner’s, hoarseness, oscillopsia (sensation of things moving back and forth in horizontal plane), gag, vertigo) Avellis syndrome: (tegmentum of the medulla) paralysis of soft palate and vocal cord contralateral hemianesthesia[prod.wiki.cns.org]
  • Benedikt syndrome is similar to Weber syndrome, but the necrosis involves the medial lemniscus and red nucleus, producing contralateral hemianesthesia and involuntary movements of the limbs of the opposite side.[healthy--mind.blogspot.com]
  • SPINAL TRIGEMINAL NUCLEUS AND TRACT • LESIONS RESULT IN IPSILATERAL LOSS OF PAIN AND TEMPERATURE SENSATION FROM THE FACE FACIAL HEMIANESTHESIA). 8. DESCENDING SYMPATHETIC TRACT.[de.slideshare.net]
Fixed Pupils
  • pupils, hydrocephalus retraction nystagmus Dorsal Midbrain MillardGubler and Base of Raymond- Pons Foville Ocular palsies, paralysis of Tumor gaze, cerebellar ataxia VII and sometimes VI Corticospinal tract Facial and 6th palsy, contralateral Vascular[docshare.tips]
  • […] gaze and cerebellar ataxia Nothnagel syndrome Causes Parinaud Syndrome Cranial Nerves Involved Parinaud Syndrome Tracts Involved Supranuclear mechanism for forward upward gaze and periaquaductal gray matter Paralysis of upward gaze and accommodation, fixed[quizlet.com]
  • The dilated, light-fixed pupil should be apparent on inspection without requiring any co-operation from the patient.[emedicine.medscape.com]
  • Ocular palsies, paralysis of gaze, cerebellar ataxia Tumor Parinaud Dorsal Midbrain Paralysis of upward gaze and accommodation, fixed pupils, retraction nystagmus Pinealoma, hydrocephalus Wernekinck Decussation of superior cerebellar peduncle.[dizziness-and-balance.com]

Workup

Diagnosis of BS relies on a confirming the patient's stroke risk factors, on clinical investigations and on brain imaging studies. In selected cases with a possible connection to a tuberculosis infection, an analysis of cerebrospinal fluid is also necessary [1].

A patient history featuring a smoking habit, pronounced hypertension, prolonged untreated diabetes, hypercholesterolemia and a familial predisposition for stroke-related disorders are crucial parameters for the diagnosis [7][8].

Clinical examination should focus on obvious BS symptoms like ptosis, eye deviations, pupillary anomalies, contralateral hemiparesis, lack of voluntary motor coordination and tremors. Eye deviations occur because of an injury to the oculomotor nerve and force the eyes outward or downward [1].

Magnetic resonance imaging (MRI) and computer tomography (CT) scans are the final step in the workup since these methods provide the best chance to exclude other ailments with similar symptoms, e.g. cavernous sinus thrombosis. Both methods can detect disruptions in the above-mentioned midbrain areas [1] [9].

Deep brain stimulation may provide a valuable treatment option for the BS associated intention tremor [10].

Hypercholesterolemia
  • A patient history featuring a smoking habit, pronounced hypertension, prolonged untreated diabetes, hypercholesterolemia and a familial predisposition for stroke-related disorders are crucial parameters for the diagnosis.[symptoma.com]
  • Small vessel disease (diabetes, hypertension, hypercholesterolemia) is the usual cause proposed by radiologists.[dizziness-and-balance.com]

Treatment

  • Deep brain stimulation may provide a valuable treatment option for the BS associated intention tremor.[symptoma.com]
  • […] were more likely to receive treatment than the poor ... that prevented equal access to HIV/AIDs treatment ...[liquisearch.com]
  • The clinical features of this patient provide additional symptoms to the syndrome of PCA stenosis, and their recognition may hasten the diagnosis of PCA stenosis and appropriate treatment.[docshare.tips]
  • “Deep brain stimulation as an effective treatment option for post-midbrain infarction-related tremor as it presents with Benedikt syndrome”. Journal of Neurosurgery. 109 (4): 635–639. doi : 10.3171/JNS/2008/109/10/0635. PMID 18826349.[checkrare.com]
  • "Deep brain stimulation as an effective treatment option for post-midbrain infarction-related tremor as it presents with Benedikt syndrome". Journal of Neurosurgery. 109 (4): 635–639. doi : 10.3171/JNS/2008/109/10/0635. PMID 18826349.[en.wikipedia.org]

Prognosis

  • Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol. 1992 ; 113(5) : 489 –496.[aao.org]
  • Prognosis This will depend on the extent of disease; however: Acute basilar artery occlusion has a very high mortality rate. Vertebrobasilar stroke usually leaves significant neurological deficits.[patient.info]
  • The rostral basilar artery syndrome: diagnosis, etiology, prognosis. Neurology 1989 ; 39 : 9 –16. Lhermitte F. Le syndrome cérebelleux: étude anatomo-clinique chez l’adulte. Rev Neurol 1958 ; 98 : 435 –77. Mehler MF.[jnnp.bmj.com]
  • Bilateral occlusions are much rarer than unilateral, and have a slowly progressive course and poor prognosis (Caplan, 1983). MRA combined with MRI is usually the best way to make this diagnosis.[dizziness-and-balance.com]

Etiology

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • . • Small vessel disease is the prime etiology in thalamic infarcts. • The etiology of midbrain infarcts remains undetermined in up to 50% of cases.[medlink.com]
  • From Jump to: navigation, search Contents 1 Etiology 2 Epidemiology 3 Pathology 4 Clinical-manifestations 5 Management 6 More General Terms 7 References Etiology ischemic stoke hemorrhagic stroke brain tumor tuberculosis Epidemiology rare Pathology stroke[anvita.info]
  • The original reference is provided for historical interest, and review articles are included to show recent advances in etiology and treatment.[books.google.com]

Epidemiology

  • From Jump to: navigation, search Contents 1 Etiology 2 Epidemiology 3 Pathology 4 Clinical-manifestations 5 Management 6 More General Terms 7 References Etiology ischemic stoke hemorrhagic stroke brain tumor tuberculosis Epidemiology rare Pathology stroke[anvita.info]
  • Epidemiology A relatively uncommon form of stroke.[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • […] signification worked out study than one exclusively devoted to a of imaging and magnetic resonance imaging, which limited number of scientific papers. will perhaps allow us to detect ischemic edema in the After a brief clinical and pathophysiological[books.google.com]
  • This is probably because the pathophysiology of the third cranial nerve lesion involves leakage of blood from the aneurysm dome into the nerve across its outer margin.[emedicine.medscape.com]
  • Pathophysiology Atherosclerosis : the most common vascular disease affecting the vertebrobasilar system: [ 1 ] This affects large vessels, causing narrowing and occlusion.[patient.info]
  • The pathophysiology is not fully understood, but defects in T-cell and humoral homeostasis have been implicated in villous injury.[acphospitalist.org]

Prevention

  • الصفحة 1607 - Centers for Disease Control and Prevention: 1994 Revised Classification System for Human Immunodeficiency Virus Infection in Children Less Than 13 Years of Age, MMWR, 43, 1-19, No. ‏[books.google.com]
  • Lowering of insulin levels Restoration of fertility Treatment of hirsutism or acne Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer In each of these ... the major reasons for this is the lack of large[liquisearch.com]
  • Even with vertebral artery occlusion, collaterals (circle of Willis) may prevent ischaemia.[patient.info]
  • In this article, the authors present in depth the clinical correlates of midbrain and thalamic ischemic lesions, while also summarizing the advances in treatment and prevention of ischemic lesions involving the different vascular territories of the thalamus[medlink.com]
  • Serologic samples sent to the Centers for Disease Control and Prevention (CDC) and the Rhode Island Department of Health returned positive for anti-chikungunya virus IgM antibodies. The patient was discharged home after 5 days of supportive care.[acphospitalist.org]

References

Article

  1. Ruchalski K, Hathout GM. A Medley of Midbrain Maladies: A Brief Review of Midbrain Anatomy and Syndromology for Radiologists. Radiol Res Pract. 2012;258524.
  2. Khan AO. Pupil-sparing complete third nerve palsy from cryptogenic midbrain stroke in an otherwise healthy young adult with patent foramen ovale. 2012; 19(2): 237–239.
  3. Cormier PJ, Long ER, Russell EJ. MR imaging of posterior fossa infarctions: vascular territories and clinical correlates. Radiographics. 1992; 12(6):1079-1096.
  4. Fujieda T, Yamauchi T, Takahasi S, Moroji T. Letter: Effect of levodopa on tremor in Benedikt's syndrome. Br Med J. 1974; 1(5905):456-457.
  5. Afifi AK, Bergman RA. Functional Neuroanatomy: Text and Atlas. New York, NY: McGraw-Hill Companies, Health Professions Division; 1998.
  6. Hebb ALO, Brandman D, Shankar JAI, Hebb AO. Visualizing Recovery of Cognitive Function in Stroke. Journal of Behavioral and Brain Science. 2013; 3: 641-652.
  7. Spence JD. Intensive risk factor control in stroke prevention. F1000Prime Rep. 2013; 5:42.
  8. Nicol MB, Thrift AG. Knowledge of Risk Factors and Warning Signs of Stroke. Vasc Health Risk Manag. 2005; 1(2): 137–147.
  9. Nouh A, Remke J, Ruland S. Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management. Front Neurol. 2014; 5:30.
  10. Bandt SK, Anderson D, Biller J. Deep brain stimulation as an effective treatment option for post-midbrain infarction-related tremor as it presents with Benedikt syndrome. J Neurosurg. 2008; 109(4):635-639.

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Last updated: 2019-07-11 21:36