Edit concept Question Editor Create issue ticket

Millard-Gubler Syndrome

Millard%E2%80%93Gubler Syndrome

Millard-Gubler syndrome is a rare lesion of the brainstem affecting the abducens (VI) and the facial (VII) cranial nerves, as well as the pyramidal tract. Unilateral palsy of these nerves accompanied by contralateral motor weakness of the limbs is the typical clinical presentation. The diagnosis is made on clinical grounds, and the underlying cause often requires a thorough imaging workup.


Presentation

Millard-Gubler syndrome, initially described more than 150 years ago, is a lesion of the brainstem that develops in the ventral pons, and the term "ventral pontine syndrome" is often used as a synonym [1] [2] [3]. More specifically, it belongs to a group of "crossed paralysis syndrome", as it is responsible for causing facial lesions on one side and limb deficits on the other [1] [2]. Scarce reports exist regarding its etiology, but vascular insults, tumors, and infectious diseases (neurocysticercosis and tuberculosis) have been described [1] [3] [4] [5]. The clinical presentation is distinguished by unilateral palsy of the cranial nerves VI and VII (abducens and facial nerves, respectively), together with contralateral hemiparesis, as the corticospinal tract is affected before its decussation [4] [5] [6]. Hence, weakness of the lateral rectus muscle will lead to diplopia and medial deviation of the affected eye, whereas lesions of the facial nerve (responsible for innervating the muscles of facial expression, including the platysma, orbicularis oculi, mentalis, orbicularis oris, and several other), will present with deviation of the mouth angle and a variable degree of facial paralysis [1] [2] [5]. Millard-Gubler syndrome is distinguished from other similar brainstem disorders by the absence of sensory deficits, as both the medial lemniscus and the spinothalamic tracts are not damaged [1].

Ecchymosis
  • Associated signs may include otorrhea, hemo-tympanum, and mastoid ecchymosis.[umedico.com]
Painter
  • Gubler Adolphe-Marie Gubler (1821 – 1879), French physician and pharmacologist Millard–Gubler syndrome Eduard Gubler (1891–1971), Swiss painter Matthew Gray Gubler (born March 9, 1980), American actor and former fashion model Max Gubler (1898 - 1973),[howlingpixel.com]
Ear Discharge
  • There was no history of fever, headache, seizures, altered sensorium, diplopia, nasal regurgitation of feeds, trauma, ear discharge, rash, recent vaccination, and history of contact with an open or treated case of tuberculosis.[ruralneuropractice.com]
Diplopia
  • Hence, weakness of the lateral rectus muscle will lead to diplopia and medial deviation of the affected eye, whereas lesions of the facial nerve (responsible for innervating the muscles of facial expression, including the platysma, orbicularis oculi,[symptoma.com]
  • Thus the diplopia is horizontal and worse in the distance.[howlingpixel.com]
  • Symptoms include: Contralateral hemiplegia (sparing the face) due to pyramidal tract involvement Ipsilateral lateral rectus palsy with diplopia that is accentuated when the patient looks toward the lesion, due to cranial nerve VI involvement.[strokecenter.org]
  • Paralysis of the abducens (CN VI) leads to diplopia, internal strabismus, and loss of power to rotate the affected eye outward), and disruption of the facial nerves (CN VII) leads to symptoms including flaccid paralysis of the muscles of facial expression[mnemonics-usmle.blogspot.com]
  • […] paralysis syndromes , which are characterized by cranial nerves VI and VII palsies with contralateral body motor or sensory disturbances 1-3 . ipsilateral facial and contralateral body hemiplegia due to pyramidal tract involvement 1-3 isotropism and diplopia[radiopaedia.org]
Retinal Cyst
  • On fundus examination, there was no retinal cyst and evidence of papilloedema. She was oriented and hemodynamically stable. Rest of the systemic examination was unremarkable.[ruralneuropractice.com]
Cranial Nerve Involvement
  • Nerves Involved Parinaud Syndrome Tracts Involved Supranuclear mechanism for forward upward gaze and periaquaductal gray matter Paralysis of upward gaze and accommodation, fixed pupils Pinealoma and other lesions of dorsal midbrain, hydrocephalus Millard-Gubler[quizlet.com]
Dysesthesia
  • The other symptoms also have receded gradually by now 8 months after the onset only remain a slight degree of diplopia on the left lateral gaze and of dysesthesia in the right arm and leg.[jstage.jst.go.jp]
Bálint's Syndrome
  • syndrome Cortical blindness Pure alexia temporal lobe : Cortical deafness Prosopagnosia Thalamus Thalamic syndrome Other Subclavian steal syndrome Upper motor neurone lesion ( Clasp-knife response ) Lower motor neurone lesion[en.wikipedia.org]
Astereognosis
  • […] tremor ) medial ( Cerebellar ataxia ) Basal ganglia Chorea Dystonia Parkinson's disease Cortex ACA syndrome MCA syndrome PCA syndrome frontal lobe : Expressive aphasia Aboulia parietal lobe : Receptive aphasia Hemispatial neglect Gerstmann syndrome Astereognosis[en.wikipedia.org]

Workup

The diagnosis of Millard-Gubler syndrome rests on the ability of the physician to recognize this rare brainstem syndrome, which can be done only by performing a detailed physical examination. Lesions of both abducens and facial nerve, as well as hemiplegia, must be confirmed by a properly conducted neurological exam. Because of the fact that different etiologies might induce Millard-Gubler syndrome, a complete patient history should be taken as well, in order to identify whether additional symptoms could possibly point toward an infection (fever, for example) or a vascular insult (presence of additional neurological deficits). Regardless, the use of imaging studies should be advised, and computed tomography (CT), but more commonly magnetic resonance imaging (MRI), are effective methods for visualizing the ventral aspect of the pons [1] [4] [5]. More importantly, the associated lesions (tuberculomas, tumors, or cysticercus granulomas) can be readily identified using these methods [3] [5].

Taenia Solium
  • In North America, the largest number of neurosurgical cases stemming from parasitic infections involves the larval form of Taenia solium, the infectious organism causing neurocysticercosis.[scienceopen.com]
  • J Neurosci Rural Pract 2012;3:375-7 Neurocysticercosis is the most common parasitic infection of central nervous system and result from infection with the intermediate stage of Taenia solium.[ruralneuropractice.com]

Treatment

  • General Practice Notebook General Practice Notebook The information provided herein should not be used for diagnosis or treatment of any medical condition.[gpnotebook.co.uk]
  • Efficacy of treatment should be monitored by repeat CT/MRI after 3 months. [7] Our patient improved and became asymptomatic with steroid treatment and albendazole.[ruralneuropractice.com]
  • Experience of the optic neuritis treatment trial. Neurology 1997:49:1404-1413. ‎[books.google.com]
  • Master the latest advances in ophthalmology: radical changes in the management of macular disease, including the widespread introduction of VEGF inhibitor therapy; recent developments in the investigation and treatment of retinal vascular disease; new[books.google.com]
  • Clinical Eye exam: Vertical and horizontal nystagmus; Right V, VI, VII, VIII nerve palsy; gaze palsy Pathology Pontine abscess Disease/Diagnosis Millard-Gublar Syndrome Treatment Surgery Relation is Part of Case presented at the NANOS 1973 Walsh Session[collections.lib.utah.edu]

Prognosis

  • Prognosis Prognosis mainly depends on the extent and etiology of the disease. A vertebrobasilar stroke usually leaves a significant neurologic deficit. Patients with small lesions usually have a better prognosis.[ncbi.nlm.nih.gov]
  • Wittmaack-Ekbom's syndrome; RLS Overview Historical Perspective Classification Pathophysiology Causes Differentiating Restless legs syndrome from other Diseases Epidemiology and Demographics Risk Factors Screening Natural History, Complications and Prognosis[wikidoc.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]

Etiology

  • Scarce reports exist regarding its etiology, but vascular insults, tumors, and infectious diseases (neurocysticercosis and tuberculosis) have been described.[symptoma.com]
  • Etiology Causes of Millard-Gubler syndrome (MGS) vary with age.[ncbi.nlm.nih.gov]
  • Its etiology and the mechanism are discussed here. We tend to conclude that, in addition to direct damage, its mechanism can be attributed to vasostenosis of the perforators from the basilar artery compressed by the prepontine subarachnoid hematoma.[unboundmedicine.com]
  • Etiology Causes vary by age 1-3 : young tumor demyelination (e.g. MS ) viral infection (e.g. rhombencephalitis ) older vascular Lesions are in ventral aspect of caudal pons with imaging characteristics depend on underlying cause 1-3 .[radiopaedia.org]
  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]

Epidemiology

  • , in patients who have one major plus two minor criteria, in those who have one major plus one minor and one epidemiologic criterion, and in those who have three minor plus one epidemiologic criterion.[scienceopen.com]
  • The book also provides updated epidemiologic and statistical data throughout and includes a section on biostatistics in physical medicine and rehabilitation.[books.google.com]
  • Epidemiology Epidemiology varies according to the cause of the disease. Pathophysiology This syndrome is caused due to a lesion at ventral part of the pons that involves the fibers of cranial nerves VI, VII, and corticospinal tract fibers.[ncbi.nlm.nih.gov]
  • ., Wegener, HC, and Tauxe, RV Epidemiology of Campylobacter jejuni infections in the United States and other industrialized nations.[books.google.es]
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.de]
  • Pathophysiology This syndrome is caused due to a lesion at ventral part of the pons that involves the fibers of cranial nerves VI, VII, and corticospinal tract fibers.[ncbi.nlm.nih.gov]
  • ., M.D. [1] ; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D. [2] Synonyms and Keywords: Wittmaack-Ekbom's syndrome; RLS Overview Historical Perspective Classification Pathophysiology Causes Differentiating Restless legs syndrome from other[wikidoc.org]
  • Inflammatory Bowel Disease Part I: Ulcerative Colitis–Pathophysiology ... ; Millard studied ibuprofen's effect on colonocytes from rats ...... files have been observed in UC patients.151,152 ...... Markowitz H, Gubler CJ, Mahoney JP, et al.[wsqmyxwt.ga]
  • Pathophysiology Atherosclerosis : the most common vascular disease affecting the vertebrobasilar system: [ 1 ] This affects large vessels, causing narrowing and occlusion.[patient.info]

Prevention

  • Collaborative Meta-Analysis of Randomised Trials of Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients. ‎[books.google.es]
  • Secondary Prevention Cost-Effectiveness of Therapy Future or Investigational Therapies Case Studies Case #1 Actigraphy Parasomnia Disease mongering v t e Pathology of the nervous system , primarily CNS ( G00-G47 , 320-349 ) Inflammatory diseases of the[wikidoc.org]
  • Even with vertebral artery occlusion, collaterals (circle of Willis) may prevent ischaemia.[patient.info]
  • […] can improve functionality for patientswith facial palsy.The therapymust consist of exercises with mirrors, which are both low cost and easily available, and the patient must help in the execution of the movements for both biofeedback purposes and to prevent[physio-pedia.com]

References

Article

  1. Matlis A, Kleinman Y, Korn-Lubetzki I. Millard-Gubler syndrome. AJNR Am J Neuroradiol. 1994;15(1):179-181.
  2. Kesikburun S, Safaz I, Alaca R. Pontine cavernoma hemorrhage leading to Millard-Gubler syndrome. Am J Phys Med Rehabil. 2011;90(3):263.
  3. Prasad R, Kapoor K, Srivastava A, Mishra O. Neurocysticercosis presenting as Millard Gubler syndrome. J Neurosci Rural Pract. 2012;3(3):375-377.
  4. Yasuda Y, Matsuda I, Sakagami T, Kobayashi H, Kameyama M. Pontine infarction with pure Millard-Gubler syndrome: precise localization with magnetic resonance imaging. Eur Neurol. 1993;33(4):331-334.
  5. Sharif M, More V, Purandare S. Brainstem tuberculoma--presenting as Millard Gublar syndrome. Indian J Pediatr. 2010;77(6):707.
  6. Azarmina M, Azarmina H. The Six Syndromes of the Sixth Cranial Nerve. J Ophthalmic Vis Res. 2013;8(2):160-171.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-21 23:27