Astasia, asymmetrical asterixis and pretectal syndrome in thalamo-mesencephalic hemorrhage

We report a patient who presented with sudden onset instability and diplopia. On neurological examination he had asymmetrical asterixis, predominantly in the left hand, and ocular findings consistent with a pretectal syndrome. He was also unable to stand or even sit up unassisted, with a tendency to tilt his body and rotate his trunk axis to the left. Brain MRI showed a hemorrhage in the right thalamo-mesencephalic junction. This region involves important structures for the control of postural stability, motor control, ocular movements and vestibulo-ocular integration, not yet well understood. To our knowledge, this is the first reported case with the simultaneous combination of astasia, prectectal syndrome and asymmetrical asterixis.