A 56-year-old male presented with left upper and lower limb weakness and double vision on looking towards the right side of body, which were sudden in onset and persistent during the first week. Apart from being a smoker, he did not have any other risk factors for stroke. He had a past history of pulmonary tuberculosis for which he completed treatment 6 years previously. He has neither constitutional symptoms nor respiratory symptoms suggestive of active tuberculosis. Examination of the cranial nerves revealed right-side horizontal gaze palsy (abduction failure in the right eye with adduction failure in the left eye) with right INO (adduction failure in the right eye with abducting nystagmus in the left eye) (Figure 1(a)-(c)). In addition, he had right LMN type VII nerve palsy (absence of wrinkling of right forehead, difficulty in closing right eyes, weakness of blowing of right cheek, deviation of mouth towards right side) (Figure 1(d)). All the other cranial nerves and cerebellar examination were normal. Moreover, he also had upper motor neuron (UMN) type weakness in the left upper limbs (exaggerated biceps jerk, triceps jerk, and supinator jerk and increased tone) and lower limbs (exaggerated knee jerk and ankle jerk, and upgoing plantar and increased tone with ankle clonus). The rest of the systemic examinations were normal except for the higher blood pressure reading of 170/100 mmHg on admission.
All blood tests including plasma electrolytes, liver function tests, full blood count, and erythrocyte sedimentation rate (14 mm in the first hour) were normal. Non-contrast computed tomography of the brain was normal. Screening for tuberculosis did not reveal any evidence of active tuberculosis or reactivation. Cerebrospinal fluid (CSF) analysis was acellular with a total protein of 17 mg/dL. MRI of the brain confirmed an acute infarction in the right side of the pons near the midline (Figure 2). There were no areas of abnormal enhancement seen in the cerebral parenchyma or meninges.
The patient was treated with a combination of aspirin 300 mg at night for the initial 2 weeks, and then switched to clopidogrel 75 mg at night and atorvastatin 40 mg at night . Blood pressure was monitored carefully during the hospital stay and the patient did not require antihypertensive medication on discharge. Neuro-rehabilitation was arranged. After a month of follow-up, significant improvement in the horizontal gaze was observed, especially in the left eye.