POSSIBLE NINE SYNDROME A RARE PRESENTATION OF NEURO OPHTHALMIC PONTINE SYNDROME ABSTRACT Eight and a half is characterized by horizontal gaze palsy in one eye associated with internuclear ophthalmoplegia INO and ipsilateral lower motor neuron LMN type VII nerve palsy When this is associated with contralateral hemiparesis and or hemihypesthesia it is called possible NINE syndrome We report a case of 56 year old male presented with clinical signs suggestive of right side eight and a half syndrome with contralateral hemiparesis confirmed by MRI Brain having acute infarction in the same intended territory This demonstrates the importance of identifying neuro ophthalmic signs in stroke patients and correlating those appropriately will lead to precise localization of the lesion anatomically at bedside Key words internuclear ophthalmoplegia one and a half syndrome horizontal gaze palsy eight and a half syndrome nine syndrome INTRODUCTION Miller fisher first describe a variant of brainstem stroke which had the combinations of horizontal gaze palsy in one eye with ipsilateral internuclear ophthalmoplegia and named as one and a half syndrome OHS 1

When the lesion extends to adjacent structures other cranial nerves are involved adding numbers to this and making new syndromes such as eight and a half syndrome 2 nine syndrome 3 and fifteen and a half syndrome When one and a half syndrome is associated with ipsilateral lower motor neuron type VII nerve palsy it is called eight and a half syndrome Rossini et al first described a novel neuro ophthalmic pontine syndrome in 2013 when eight and a half syndrome is associated with other clinical signs such as hemiparesis and hemihypesthesia in contralateral limbs and coined the term as possible NINE syndrome CASE PRESENTATION A 56 year old male presented with left upper and lower limb weakness and diplopia while looking at right horizontal gaze Examination revealed right side horizontal gaze palsy with right internuclear ophthalmoplegia In addition he had right lower motor neuron type VII nerve palsy All the other cranial nerves were normal as the cerebellar examination Moreover he also had cortical type weakness in left upper and lower limbs with the power of 3 5 and exaggerated deep tendon reflexes These neurological signs were sudden in onset and persistent during the first week Rest of the systems were normal except the higher blood pressure reading of 170 100 mmHg on admission Except being a smoker he did not have any traditional risk factors for stroke He had a past history of treatment completed pulmonary tuberculosis 6 years back He has neither constitutional symptoms nor respiratory symptoms suggestive of active tuberculosis 

All the preliminary investigations were normal including erythrocyte sedimentation rate ESR 14mm 1st hour Non contrast CT Brain was reported as having normal cerebral hemisphere and brainstem Screening of tuberculosis did not reveal any evidence of active tuberculosis or reactivation Lumbar puncture was performed and cerebrospinal fluid CSF analysis showed a clear CSF with the total protein of 17 mg dl Polymorphs and lymphocytes were nil Finally MRI Brain confirmed an acute infarction in the right side of the pons near to the midline Other investigations such as magnetic resonance angiography serum vasculitic profile anti neuromyelitis optica NMO antibodies and CSF oligoclonal bands had not been done Patient was treated with antiplatelets and statins Blood pressure were monitored carefully during the hospital stay which did not warrant any antihypertensive on discharge Neuro rehabilitation was arranged After a month of follow up horizontal haze improved significantly especially in the left eye and improvement in the power of the limbs were too noted Discussion Eight and a half syndrome is not uncommon clinical entity among brainstem stroke It is caused by lesion in dorsal tegmentum of pons due to the involvement of either abducens nucleus or parapontine reticular formation PPRF and medial longitudinal fasciculus MLF combined with adjacent facial nerve fascicle or colliculus 5

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