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].

• Disability

  The term originated from the Greek words "iridos" which means colored circle and "paralyein" which means to disable. The definition is from the "Taber's Cyclopedic Medical Dictionary," published by F.A.... [connection.ebscohost.com]

  The recovery differs from one person to another: from six weeks to six months and others with more significant damage may have a more permanent disability. [braininjury-explanation.com]

  Smoking. [ 5, 8 ] Presentation Death or major disability is the result of occlusion of large vessels in the vertebrobasilar system. However, many lesions arise in smaller vessels with a wide variety of focal neurological deficits. [patient.info]

  […] topographic diagnosis (site of the pathology) Clinical clue table – differentiating vestibular, cerebellar and sensory ataxia History/exam Vestibular Cerebellar Sensory Vertigo present if the vestibulopathy is acute and unilateral often intense and disabling [lifeinthefastlane.com]

• Falling

  The co-author of The Receding Shadow of the Prophet: The Rise and Fall of Political Islam, Gvosdev has published over 50 articles, columns, and essays on democratization and human rights; general foreign policy; energy policy; foreign policy of Russia [books.google.ro]

  […] 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]

  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]

  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]

  Small vessel disease (diabetes, hypertension, hypercholesterolemia) is the usual cause proposed by radiologists. [dizziness-and-balance.com]

• 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]

  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]

  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]

  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]

• 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]

• 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]

  Signs and symptoms It is characterized by the presence of an oculomotor nerve (CN III) palsy and cerebellar ataxia including tremor. [checkrare.com]

• Chorea

  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]

  Post-hemiplegic chorea Postseizure paralysis Spastic cerebral palsy Spinal cord injury C1 level, brown sequard syndrome Spinal cord injury C2 level, brown sequard syndrome Spinal cord injury C3 level, brown sequard syndrome Spinal cord injury C4 level [icd9data.com]

  Midbrain syndromes Benedikt’s -Ipsilateral Oculomotor palsy and CL tremors,chorea,athetosis.Injury to red nucleus Nothnagel’s -IL 3rd N palsy and CL cerebellar ataxia.Due to superior cerebellar peduncle injury Claude’s- Benedikt’s Nothnagel’s Webers - [masterofmedicine.com]

  Benedikt syndrome ventral tegmentum, PCA Parinaud's syndrome dorsal, tumor Nothnagel's syndrome Claude's syndrome Other Alternating hemiplegia Cerebellum lateral ( Dysmetria Dysdiadochokinesia Intention tremor ) medial ( Cerebellar ataxia ) Basal ganglia Chorea [en.wikipedia.org]

  Contralateral tremor, ataxia or chorea. Posterior cerebral artery occlusion: Most often causes occipital lobe infarction with hemianopia and macular sparing. Variable effects from thalamic syndrome to varieties of cortical visual disturbance. [patient.info]

• Mydriasis

  […] syndrome: abulia (absence of initiative) Parinaud’s CN III palsy Remember: PA 3 (Parinaud’s, Abulia, CN 3) Nothnagel syndrome: unilateral or bilateral CN III cerebellar ataxia; Remember Benedikt - hemiplegia Parinaud’s syndrome: loss of upward gaze mydriasis [prod.wiki.cns.org]

  The injury to the third cranial nerve causes a LMN paralysis of the ipsilateral extraocular muscles innervated by the oculomotor nerve and a dilated pupil (mydriasis) because of loss of parasympathetic fibers (see Basal Region of the Midbrain). [aibolita.com]

  Initially, physical findings attributable to involvement of the third cranial nerve are described (eg, ptosis, mydriasis, ophthalmoplegia). [emedicine.medscape.com]

  Ipsilateral mydriasis, cranial nerve III palsy and ptosis. Contralateral hemiplegia. Benedikt's syndrome: Dorsal midbrain affected. Ipsilateral oculomotor effects as in Weber's syndrome. Contralateral tremor, ataxia or chorea. [patient.info]

• Hyperactivity

  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]

  It should be noted that PET scans taken in situations in which the patient is hyperactive or shivering can give false-positive readings. [what-when-how.com]

  Physical exam revealed a nontender abdomen and hyperactive bowel sounds. Infectious workup for Clostridium difficile, Shigella, Campylobacter, Escherichia coli, Salmonella, Giardia, and Isospora was negative. CT scan of the abdomen was unrevealing. [acphospitalist.org]

  agitation, hyperactivity, abulia, contralateral neglect), and language impairment [ 63 ]. Movement disorders are unusual following ACA territory infarcts. A minority of patients with small anterior frontal lesions may exhibit asterixis. [neupsykey.com]

• Excitement

  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]

  Due to expansion and growth, we have an exciting opportunities for GIS Technicians to work with us in the vibrant city of Kilkenny! [ipone.ie]

  Benedikt's Syndrome describes an ipsilateral III nerve palsy accompanied by contralateral 'cerebellar' tremor - a slow rhythmic tremor of the contralateral hand and foot, increased by excitement and voluntary movement, absent in sleep. [gpnotebook.co.uk]

  Rarely, nondominant infarction may cause an acute confusional state and acute agitated delirium with affective and autonomic excitement, delusions, and hallucinations [ 226 ]. [neupsykey.com]

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]

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.