Incorrect

Correct! This patient has a palsy of right horizontal conjugate gaze (“gaze palsy”) that involves saccades, pursuit, and the vestibulo-ocular reflex. Although you could postulate lesions affecting the extraocular muscles or the neuromuscular junction activated in right gaze, such a symmetrical deficit of conjugate gaze to one side will virtually always originate within the brain. If volitional and reflex gaze are both completely impaired, expect to find the lesion in the pons. You should be surprised that there are no other neurologic deficits--seventh nerve palsy, internuclear ophthalmoplegia, nystagmus, ataxia, skew deviation, or limb weakness. However, a lesion confined to a small area in the tegmental pons—in the location of the sixth nerve nucleus-- might not produce any obvious accompanying signs (although you should look for them as “fellow travelers”). This patient had a hemorrhage from a right pontine tegmental cavernous malformation (“cavernoma”).

The only effective treatment is surgical excision, which is hazardous. No treatment was undertaken in this case. The patient’s deficits gradually resolved enough to give him partial restoration of right gaze. He was advised to avoid any activity that would generate increased intracranial pressure (like weight-lifting, evacuative straining, and standing on his head!)

Incorrect