Sixth cranial nerve palsy and contralateral hemiparesis (Raymond’s syndrome) sparing the face

Abstract

A 74-year old man presented with horizontal diplopia of sudden onset, worsened by directing gaze to the left. His past medical history included arterial hypertension treated with an angiotensin conversion enzyme inhibitor, a 60pack-per-year smoking history and moderate alcohol consumption. Neurological examination showed moderate left VIth nerve paresis and slight paresis of the right arm and leg. Both spontaneous and voluntary facial movements were normal. Deep tendon reflexes were normal and symmetric. Cutaneous plantar response was flexor on both sides. There was no ataxia or sensory deficit. Gait was unremarkable. Laboratory examinations were normal except for slightly raised liver enzymes. Magnetic resonance imaging, performed 2 days after the onset of symptoms, showed a lesion in the left caudal ventral paramedian pons (Fig. 1a, b). Magnetic resonance angiography as well as extraand intracranial ultrasound with Doppler examination did not reveal any hemodynamically significant arterial stenosis. Heart rhythm remained regular during 24-h monitoring in the stroke unit. The patient was not handicapped by the slight hemiparesis; diplopia resolved partially over several days. Acetylsalicylic acid was introduced.