A rare presentation of subarachnoid hemorrhage: Vertical gaze palsy – A case report

Abstract

This case of vertical gaze palsy due to mesencephalon hemorrhage represents an unusual presentation of subarachnoid hemorrhage (SAH). A 28-year-old male patient presented with acute onset of headache and vertical diplopia. On admission he had no neurological deficit except for slightly limited vertical eye movements of the left eye. Three hours after onset, he was slightly lethargic; vertical gaze palsy became more prominent; ptosis developed, which was more evident on the left side; and the left pupil became mydriatic. He became unconscious and was taken for an operation for ventricular drainage, but he died. Magnetic resonance imaging (MRI) angiography of the brain showed tortuous vascular structures in the posterior mesencephalon, evaluated as arteriovenous malformation. Conclusion: Spontaneous midbrain hemorrhages are very rare but extremely life-threatening clinical conditions that most frequently present with oculomotor disorders such as ptosis and vertical gaze palsy. In young SAH patients, MRI angiography is considered the gold standard to elucidate the underlying etiology, which is vascular malformation most of the time.