Pontine syndromes

Lateral pontine syndrome (Marie-Foix syndrome)

Lesion in the lateral pons, including the middle cerebellar peduncle.

May be caused by infarct in the territory of the long circumferential branches of the basilar artery.

  • Ipsilateral ataxia in the arm and leg
  • Contralateral weakness in the arm and leg
  • Contralateral hemisensory loss of pain and temperature modalities

Ventral Pontine syndrome (Millard-Gubler syndrome)

Lesion in the basis pontis and fascicles of abducens and facial nerves.

May be caused by infarct in the territory of the short circumferential and paramedian branches of the basilar artery.

  • Contralateral weakness in the arm and leg
  • Ipsilateral abducens nerve palsy
  • Ipsilateral LMN type of facial weakness

Ventral Pontine syndrome (Raymond syndrome)

Lesion in the ventral medial pons.

May be caused by infarct in the territory of the paramedian branches of the basilar artery.

  • Ipsilateral abducens nerve palsy
  • Contralateral weakness of arm and leg

Inferior Medial Pontine syndrome (Foville syndrome)

Lesion in the dorsal pontine tegmentum in the caudal third of the pons.

May be caused by infarct in the territory of the short circumferential and paramedian branches of the basilar artery.

  • Contralateral weakness in arm and leg
  • Ipsilateral LMN type weakness in the face
  • Ipsilateral lateral gaze palsy

Brissaud-Sicard syndrome

Lesion involving the anterolateral and inferior pons.

  • Ipsilateral facial cramps
  • Contralateral hemiparesis

Facial colliculus syndrome

Caused by lesion of the facial colliculus involving abducens nerve nucleus, facial nerve fascicles and medial longitudinal fasciculus.

  • Ipsilateral LMN type of facial palsy
  • Loss of taste in anterior 2/3 of ipsilateral tongue
  • Ipsilateral hyperacusis
  • Horizontal conjugate gaze palsy towards the side of the lesion
  • Diplopia

Gasperini syndrome

Caused by lesion in the caudal pons tegmentum involving nuclei of cranial nerves V, VI, VII, VIII and the spinothalamic tract.

  • Ipsilateral facial sensory loss
  • Ipsilateral impaired eye abduction
  • Ipsilateral facial palsy and hyperacusis
  • Vertigo and ipsilateral nystagmus
  • Contralateral hemi-sensory impairment of pain and temperature perception

Raymond-Céstan syndrome

Caused by occlusion of the long circumferential branches of the basilar artery involving the superior and middle cerebellar peduncles, sensory and motor nuclei and tracts of CN V, spinothalamic tract, medial lemniscus and corticospinal tract.

  • Ipsilateral ataxia
  • Ipsilateral intention tremor
  • Ipsilateral paralysis of muscles of mastication
  • Contralateral hemi-sensory impairment (all sensory modalities) in the body
  • Contralateral hemiparesis of face and body
  • Horizontal gaze palsy may coexist

Pure motor stroke

May be caused by paramedian pontine infarcts.

  • May be indistinguishable from capsular infarct on clinical grounds
  • Combination with dysarthria and history of transient gait disturbance or vertigo suggests pontine location

Ataxic hemiparesis

May be caused by paramedian pontine infarction

Dysarthria-hemiataxia and quadrataxic hemiparesis are variant presentations.

Dysarthria-clumsy hand syndrome

May be caused by infarcts in the basis pontis.

  • Dysarthria
  • Clumsiness in contralateral hand, often characterized by dysmetria, dysrhythmia, dysdiadochokinesia
  • Truncal and gait ataxia may also exist
  • Mild weakness of the affected limb may also exist

Ocular movement abnormalities

Infarcts in the basis pontis may present with a number of ocular movement abnormalities in addition to hemiparesis and sensory dysfunction.

  • Abducens nerve palsy
  • Intranuclear ophthalmoplegia (INO)
  • Horizontal gaze palsy
  • One-and-a-half syndrome (conjugate horizontal gaze palsy in one direction and INO in the other)
  • Smooth-pursuit deficit in ipsilateral eye

Cranial nerve palsies

  • Isolated abducens nerve palsy
  • Vertical gaze palsy of the opposite eye
  • Multiple cranial nerve palsies

Masticator weakness

May be caused by infarction in the lateral inferior pons affecting trigeminal nuclei. Trigeminal sensory deficit, facial weakness of LMN type and palatal weakness may also exist.

Pure sensory stroke

May be caused by infarcts in the paramedian dorsal pontine area but may be also seen in infarcts of the medial or lateral pontine tegmentum.

Sensory symptoms may be localized to the hand or mouth or have a hemi-body distribution.

Bilateral pontine infarct

Usually caused by basilar artery occlusion. Notably, basilar artery thrombosis may present with very mild neurological symptoms in the initial stages which may last for days before progressing.

  • Disturbance of consciousness
  • Pupillary and eye-movement abnormalities
  • Hemiplegia or quadriplegia
  • Cranial nerve palsies
  • Vertigo
  • Headache
  • Diplopia and blurred vision
  • Dysarthria
  • Pseudobulbar symptoms including pseudobulbar affect
  • Locked-in syndrome
    • Quadriplegia
    • Aphonia
    • Impairment of horizontal eye movements may exist

Other uncommon symptoms

  • Tonic spasms affecting the paretic limb have been described in ventral pons infarcts
  • Pathological laughing has been observed in a few patients with basal pontine infarcts