Benedikt Syndrome

Neurology

Clinicals - History

Fact Explanation
Introduction to the disease It is a rare form of posterior circulation stroke of the brain. A lesion within the tegmentum of the midbrain can produce Benedikt Syndrome.. Disease is characterized by ipsilateral third nerve palsy with contralateral hemitremor.. Introduction to the disease
It is a rare form of posterior circulation stroke of the brain. A lesion within the tegmentum of the midbrain can produce Benedikt Syndrome.. Disease is characterized by ipsilateral third nerve palsy with contralateral hemitremor..
Diplopia Diplopia or the double vision resulted due to ipsilateral oculomotor nerve palsy resulted due to involvement of oculomotor nucleus.. Diplopia
Diplopia or the double vision resulted due to ipsilateral oculomotor nerve palsy resulted due to involvement of oculomotor nucleus..
Contralateral hemiparesis Damage to the other structurs such as corticospinal tract resulted in contralateral hemiparesis. It is a distinct finding in Benedikt's syndrome.. Contralateral hemiparesis
Damage to the other structurs such as corticospinal tract resulted in contralateral hemiparesis. It is a distinct finding in Benedikt's syndrome..
Tremor Fascicular injury in the area of the red nucleus can leads to oculomotor nerve palsy with contralateral hemitremor due to damage to cerebral afferents to the thalamus.. Some studies suggest that mechanism of tremor in Benedikt's syndrome is associated with the cerebellofugal pathway and the rubrospinal tract. .Different names including rubral tremor, midbrain tremor, thalamic tremor etc are used to describe this tremor.. Tremor
Fascicular injury in the area of the red nucleus can leads to oculomotor nerve palsy with contralateral hemitremor due to damage to cerebral afferents to the thalamus.. Some studies suggest that mechanism of tremor in Benedikt's syndrome is associated with the cerebellofugal pathway and the rubrospinal tract. .Different names including rubral tremor, midbrain tremor, thalamic tremor etc are used to describe this tremor..
Ataxia Superior cerebellar peduncle and/or red nucleus damage in Benedikt Syndrome can further lead in to contralateral cerebellar hemiataxia.. Ataxia
Superior cerebellar peduncle and/or red nucleus damage in Benedikt Syndrome can further lead in to contralateral cerebellar hemiataxia..
History of smoking Smoking is a known risk factor for stroke.Smoking can increases the risk of stroke by about 6 folds.. History of smoking
Smoking is a known risk factor for stroke.Smoking can increases the risk of stroke by about 6 folds..
History of hypertention Hypertension is identified risk factor for development of stroke. About 90% of strokes occur in patients with resistant hypertension ,among patients who receiving treatment for hypertension,HT has a contribution for atherosclerosis. But HT itself causes small vessel disease lead in to stroke. History of hypertention
Hypertension is identified risk factor for development of stroke. About 90% of strokes occur in patients with resistant hypertension ,among patients who receiving treatment for hypertension,HT has a contribution for atherosclerosis. But HT itself causes small vessel disease lead in to stroke.
History of diabetes Diabetes also a known risk factor for development of stroke.. History of diabetes
Diabetes also a known risk factor for development of stroke..
History of hypercholesterolemia Hypercholesterolemia increase the risk of atherosclerosis thereby increase risk of stroke.,. History of hypercholesterolemia
Hypercholesterolemia increase the risk of atherosclerosis thereby increase risk of stroke.,.
Family history of stroke Having positive family history of stroke increase the risk of individual to get a stroke.. Family history of stroke
Having positive family history of stroke increase the risk of individual to get a stroke..

Clinicals - Examination

Fact Explanation
Ptosis Ptosis or drooping of eye lid also a manifestation of 3rd nerve palsy. 3rd nerve palsy causes paralysis of the levator palpebrae muscle that results in ptosis.. Ptosis
Ptosis or drooping of eye lid also a manifestation of 3rd nerve palsy. 3rd nerve palsy causes paralysis of the levator palpebrae muscle that results in ptosis..
Deviation of the eye Eye is deviated to Downward and outward.Occurs due to ipsilateral third nerve palsy. Injury to the oculomotor nerve causing damage to the extraocular muscles results in downward and lateral deviation of the eye.. Deviation of the eye
Eye is deviated to Downward and outward.Occurs due to ipsilateral third nerve palsy. Injury to the oculomotor nerve causing damage to the extraocular muscles results in downward and lateral deviation of the eye..
Dilated unresponsive pupils Examination of pupils will show dilated unresponsive pupils. These afferent pupillary defect is a manifestation of 3rd nerve palsy.. Dilated unresponsive pupils
Examination of pupils will show dilated unresponsive pupils. These afferent pupillary defect is a manifestation of 3rd nerve palsy..
Contralateral hemiparesis Damage to the corticospinal tracts will result contralateral hemiparesis.. Contralateral hemiparesis
Damage to the corticospinal tracts will result contralateral hemiparesis..
Motor incoordination Involvement of the superior cerebellar peduncle and/or red nucleus cause motor incoordination.. Motor incoordination
Involvement of the superior cerebellar peduncle and/or red nucleus cause motor incoordination..
Ataxia Gait assessment during examination reveals cerebellar contralateral ataxia. Occurs due to an insult to the structures such as red nucleus and fibers of the superior cerebellar peduncle. Ataxia
Gait assessment during examination reveals cerebellar contralateral ataxia. Occurs due to an insult to the structures such as red nucleus and fibers of the superior cerebellar peduncle.
Higher function assessment findings. It includes memory, orientation, language and attention.Cognitive deficits appear in approximately 30% of stroke patients. However it is found to be unimpaired in most patients with Benedikt syndrome., Higher function assessment findings.
It includes memory, orientation, language and attention.Cognitive deficits appear in approximately 30% of stroke patients. However it is found to be unimpaired in most patients with Benedikt syndrome.,

Investigations - Diagnosis

Fact Explanation
MRI Brain Benedikt syndrome diagnosis is suspected mainly by clinical history and examination. Then go for investigations. Diffusion weighted imaging (DWI) is a common form of MRI that has been used. It will show involvement of superior cerebellar peduncle and/or red nucleus, as well as the oculomotor fascicle.And it is useful to exclude certain other pathology such as ICH, ischemia, Tuberculous meningitis, cavernous sinus thrombosis ect..,,. MRI Brain
Benedikt syndrome diagnosis is suspected mainly by clinical history and examination. Then go for investigations. Diffusion weighted imaging (DWI) is a common form of MRI that has been used. It will show involvement of superior cerebellar peduncle and/or red nucleus, as well as the oculomotor fascicle.And it is useful to exclude certain other pathology such as ICH, ischemia, Tuberculous meningitis, cavernous sinus thrombosis ect..,,.
CT brain Even though CT not well differentiated the mid brain nuclei and fiber tracts they are useful in assessment of visible mid brain anatomy and related pathology. CT is also useful in exclusion of certain other diseases mentioned under Differential diagnosis.. CT brain
Even though CT not well differentiated the mid brain nuclei and fiber tracts they are useful in assessment of visible mid brain anatomy and related pathology. CT is also useful in exclusion of certain other diseases mentioned under Differential diagnosis..
CSF analysis It plays a key role in diagnosis of Tuberculous Meningitis which is one of the differential diagnosis. It will show lymphocytic pleocytosis, with an elevated protein and low glucose levels.. CSF analysis
It plays a key role in diagnosis of Tuberculous Meningitis which is one of the differential diagnosis. It will show lymphocytic pleocytosis, with an elevated protein and low glucose levels..

Investigations - Management

Fact Explanation
Full blood count FBc like basic blood tests are performed to rule out infections.. Full blood count
FBc like basic blood tests are performed to rule out infections..
Blood glucose level Random blood sugar level should be test for the assessment of DM causing hypo or hyperglycemia. . Blood glucose level
Random blood sugar level should be test for the assessment of DM causing hypo or hyperglycemia. .
Serum electrolytes Carried out to find whether there is associated electrolyte disturbances.. Serum electrolytes
Carried out to find whether there is associated electrolyte disturbances..
Blood urea and serum creatinine Carried out as a routine laboratory investigation to assess renal functions.. Blood urea and serum creatinine
Carried out as a routine laboratory investigation to assess renal functions..
ECG Used to diagnose whether there is ongoing cardiac ischemia or other cardiac pathology.. ECG
Used to diagnose whether there is ongoing cardiac ischemia or other cardiac pathology..

Management - Supportive

Fact Explanation
Adimit,assessment of airway breathing ,circulation and other relevant examinations Admit the patient to a multidisciplinary stroke unit. After taking a brief history have to go quickly for examination starting from ABC (airway, breathing, circulation) and manage them properly. Mean time look for blood pressure, oxygen saturation, sign of carotid bruits, peripheral pulses, cardiac auscultation, and if there are any serious abnormalities try to correct them and maintain good saturation by providing oxygen via mask. Adimit,assessment of airway breathing ,circulation and other relevant examinations
Admit the patient to a multidisciplinary stroke unit. After taking a brief history have to go quickly for examination starting from ABC (airway, breathing, circulation) and manage them properly. Mean time look for blood pressure, oxygen saturation, sign of carotid bruits, peripheral pulses, cardiac auscultation, and if there are any serious abnormalities try to correct them and maintain good saturation by providing oxygen via mask.
Assessment of GCS and neuroimagine Quickly assess the GCS .Mean time look for head trauma and signs of seizures such as tongue laceration, and if the GCS is low go for relevant management options.Brain imaging have to be performed immediately for patients with persistent neurological symptoms.. Assessment of GCS and neuroimagine
Quickly assess the GCS .Mean time look for head trauma and signs of seizures such as tongue laceration, and if the GCS is low go for relevant management options.Brain imaging have to be performed immediately for patients with persistent neurological symptoms..
Thrombolytic theraphy When CT brain excludes the presence of hemorrhage, can go for thrombolitic theraphy. Tissue plasminogen activator such as alteplase can use if present early with acute ischemic stroke.150 mg of aspirin should be given to all ischemic stroke patients immediately after brain imaging has excluded intracranial hemorrhage. It should be continued until 2 weeks after the onset of stroke symptoms. And antiplatelet or anticoagulant agent is started for secondary prevention. Proton pump inhibitors can be used if patient developed dyspepsia to Asprin. . Thrombolytic theraphy
When CT brain excludes the presence of hemorrhage, can go for thrombolitic theraphy. Tissue plasminogen activator such as alteplase can use if present early with acute ischemic stroke.150 mg of aspirin should be given to all ischemic stroke patients immediately after brain imaging has excluded intracranial hemorrhage. It should be continued until 2 weeks after the onset of stroke symptoms. And antiplatelet or anticoagulant agent is started for secondary prevention. Proton pump inhibitors can be used if patient developed dyspepsia to Asprin. .
Antithrombotic or fibrinolytic therapy in ICH If ICH occurs due to IV heparin, normalization of a-PTT have to be carried out with antidote called protamine sulphate. if there is a warfarin related ICH should be managed with vitamin K or fresh frozen plasma (FFP) . If the ICH is related to thrombolysis, it should be treated with infusion of platelets. . Antithrombotic or fibrinolytic therapy in ICH
If ICH occurs due to IV heparin, normalization of a-PTT have to be carried out with antidote called protamine sulphate. if there is a warfarin related ICH should be managed with vitamin K or fresh frozen plasma (FFP) . If the ICH is related to thrombolysis, it should be treated with infusion of platelets. .
Neurosurgery Neurosurgery is occasionally needed in case of massive ICH.. Neurosurgery
Neurosurgery is occasionally needed in case of massive ICH..
Supportive care After patient get recover from the acute event ask them to change the posture, siting, standing and walking with caution in order to prevent secondary complications. Assess the swallowing by bedside water swallow test. Can introduce nasogastric tube if there is a swallowing difficulty.. Supportive care
After patient get recover from the acute event ask them to change the posture, siting, standing and walking with caution in order to prevent secondary complications. Assess the swallowing by bedside water swallow test. Can introduce nasogastric tube if there is a swallowing difficulty..
Early mobilization Passive full range-of-motion exercises for paralyzed limbs should be started with in first 24 hours. They should be referred to physiotherapist or rehabilitation team.. Early mobilization
Passive full range-of-motion exercises for paralyzed limbs should be started with in first 24 hours. They should be referred to physiotherapist or rehabilitation team..
Nutritional support Nutritional assessment should be carried out with in 48h of admission.Consider nutritional support in malnourished patients.. Nutritional support
Nutritional assessment should be carried out with in 48h of admission.Consider nutritional support in malnourished patients..
Prophylactic anticoagulant therapy Patients with paralyzed legs due to ischemic stroke should be given either standard heparin (5000 units subcutaneous b.d.) or LMW heparin in order to prevent deep vein thrombosis.. Prophylactic anticoagulant therapy
Patients with paralyzed legs due to ischemic stroke should be given either standard heparin (5000 units subcutaneous b.d.) or LMW heparin in order to prevent deep vein thrombosis..
Bladder bowel care Indwelling catheter can be used because patient is having hemiparesis and difficult to walk to the toilet. Use oral laxatives and maintain good fluid intake in order to overcome constipation.. Bladder bowel care
Indwelling catheter can be used because patient is having hemiparesis and difficult to walk to the toilet. Use oral laxatives and maintain good fluid intake in order to overcome constipation..

Management - Specific

Fact Explanation
Antiplatelet therapy All patients with ischemic stroke should take anti platelet therapy for secondary prevention. Aspirin (30-300 mg/day) or combination of aspirin (25 mg) with extended release dipyridamole (200 mg) twice or clopidogrel (75 mg OD) are the initially used anti platelet therapy.. Antiplatelet therapy
All patients with ischemic stroke should take anti platelet therapy for secondary prevention. Aspirin (30-300 mg/day) or combination of aspirin (25 mg) with extended release dipyridamole (200 mg) twice or clopidogrel (75 mg OD) are the initially used anti platelet therapy..
Anticoagulation Used if there is an associated AF or patients with ischemic stroke associated with mitral valve disease, prosthetic heart valves, or even within 3 months of MI. Heparin and warfarin can be used.. Anticoagulation
Used if there is an associated AF or patients with ischemic stroke associated with mitral valve disease, prosthetic heart valves, or even within 3 months of MI. Heparin and warfarin can be used..
Blood pressure lowering Useful in secondary prevention. Try to maintain BP less than 130/80 mmHg with the help of anti hypertensive drugs.. Blood pressure lowering
Useful in secondary prevention. Try to maintain BP less than 130/80 mmHg with the help of anti hypertensive drugs..
Lipid lowering therapy All patients with ischemic stroke should be treated with a statin for secondary prevention,if they have a total cholesterol of > 200 mg%, or LDL cholesterol > 100 mg%. Try to maintain total cholesterol below 200mg/dl and LDL below 100mg/dl.. Lipid lowering therapy
All patients with ischemic stroke should be treated with a statin for secondary prevention,if they have a total cholesterol of > 200 mg%, or LDL cholesterol > 100 mg%. Try to maintain total cholesterol below 200mg/dl and LDL below 100mg/dl..
Life style modification Ask them to cessation of smoke if they are already smoking. Ask to do regular aerobic exercise at least 30 minutes per day. Advice them to take healthy diet which contain low fat and inform about safe level of alcohol.. Life style modification
Ask them to cessation of smoke if they are already smoking. Ask to do regular aerobic exercise at least 30 minutes per day. Advice them to take healthy diet which contain low fat and inform about safe level of alcohol..
Nonsurgical conservative treatment of ptosis Those treatment methods include eye-putti ,eyelash glue and glasses which made with a crutch attachment to hold up the lid.. Nonsurgical conservative treatment of ptosis
Those treatment methods include eye-putti ,eyelash glue and glasses which made with a crutch attachment to hold up the lid..
Levodopa Studies suggest that levodopa which act as precursor to the neurotransmitters such as dopamine can use to treat tremors in benedikt syndrome.,. Levodopa
Studies suggest that levodopa which act as precursor to the neurotransmitters such as dopamine can use to treat tremors in benedikt syndrome.,.
Deep brain stimulation Deep brain stimulation may provide relief from some symptoms of Benedikt syndrome, specially the tremors associated with the disorder.. Deep brain stimulation
Deep brain stimulation may provide relief from some symptoms of Benedikt syndrome, specially the tremors associated with the disorder..

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. ALUSI S. H.. Stereotactic lesional surgery for the treatment of tremor in multiple sclerosis: A prospective case-controlled study. [online] 2001 August, 124(8):1576-1589 [viewed 06 October 2014] Available from: doi:10.1093/brain/124.8.1576
  2. FUJIEDA T, YAMAUCHI T, TAKAHASHI S, MOROJI T. Letter: Effect of levodopa on tremor in Benedikt's syndrome. Br Med J [online] 1974 Mar 9, 1(5905):456-457 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633264
  3. HEBB ANDREA L. O., BRANDMAN DAVID, SHANKAR JAI, HEBB ADAM O.. Visualizing Recovery of Cognitive Function in Stroke. JBBS [online] 2013 December, 03(08):641-652 [viewed 06 October 2014] Available from: doi:10.4236/jbbs.2013.38067
  4. KHAN ARIFO. Pupil-sparing complete third nerve palsy from cryptogenic midbrain stroke in an otherwise-healthy young adult with patent foramen ovale. Middle East Afr J Ophthalmol [online] 2012 December [viewed 06 October 2014] Available from: doi:10.4103/0974-9233.95260
  5. KIM SOO YEON, PARK HYE KYUNG, SONG DAE HEON, CHUNG MYUNG EUN, KIM YOUNG MOON, WOO JAE HYUN. Management of Severe Bilateral Ptosis in a Patient With Midbrain Infarction: A Case Report. Ann Rehabil Med [online] 2013 December [viewed 06 October 2014] Available from: doi:10.5535/arm.2013.37.6.891
  6. NICOL MB, THRIFT AG. Knowledge of Risk Factors and Warning Signs of Stroke Vasc Health Risk Manag [online] 2005 Jun, 1(2):137-147 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993942
  7. NOUH AMRE, REMKE JESSICA, RULAND SEAN. Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management. Front. Neurol. [online] 2014 April [viewed 06 October 2014] Available from: doi:10.3389/fneur.2014.00030
  8. PRASAD KAMESHWAR, PADMA MV, KHURANA DHEERAJ, KAUL SUBHASH, GORTHI SP, BAKSHI ASHA. Stroke management. Ann Indian Acad Neurol [online] 2011 December [viewed 06 October 2014] Available from: doi:10.4103/0972-2327.83084
  9. RUCHALSKI KATHLEEN, HATHOUT GASSER M.. A Medley of Midbrain Maladies: A Brief Review of Midbrain Anatomy and Syndromology for Radiologists. Radiology Research and Practice [online] 2012 December, 2012:1-11 [viewed 06 October 2014] Available from: doi:10.1155/2012/258524
  10. SPENCE J. DAVID. Intensive risk factor control in stroke prevention. F1000Prime Rep [online] 2013 October [viewed 06 October 2014] Available from: doi:10.12703/P5-42
  11. VINNARD C, MACGREGOR RR. Tuberculous Meningitis in HIV-Infected Individuals Curr HIV/AIDS Rep [online] 2009 Aug, 6(3):139-145 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3131531
  12. WOO JH, HONG BY, KIM JS, MOON SH, KIM SY, HAN HY, PARK DY, LIM SH. Holmes Tremor After Brainstem Hemorrhage, Treated With Levodopa Ann Rehabil Med [online] 2013 Aug, 37(4):591-594 [viewed 06 October 2014] Available from: doi:10.5535/arm.2013.37.4.591