From Eight-and-a-Half to Nine: A Case Report Highlighting an Uncommon Brainstem Syndrome

Nine syndrome is a rare clinical brainstem syndrome combining one-and-a-half syndrome with ipsilateral facial weakness and long-tract signs such as contralateral hemiparesis or hemiataxia. It typically results from pontine tegmentum lesions, most often due to acute ischemic stroke. We conducted a systematic review of published cases using PubMed, Scopus, and Web of Science (search until October 2025). Data on demographics, clinical features, imaging, etiology, and outcomes were summarized descriptively.

A 73-year-old woman with vascular risk factors presented with diplopia, ipsilateral facial weakness, and contralateral arm weakness, consistent with nine syndrome. MRI revealed infarction in the left dorsal pons and ventral medulla. Stroke etiology was attributed to small-vessel ischemic disease. She was started on dual antiplatelet as well as aggressive risk factor management. At 4-month follow-up, her motor symptoms had largely improved, albeit with residual diplopia. Literature review identified 25 cases with similar presentation (mean age 57.7 years; 66.7% male). Contralateral hemiparesis occurred in 52%, hemiataxia in 24%, and sensory deficits in 32%. Ischemic stroke was the leading cause (68%), followed by hemorrhagic stroke (20%) and demyelinating conditions (12%). Complete recovery was rare (4%), with most cases showing partial improvement.

Nine syndrome reflects a strategically located pontine lesion disrupting multiple adjacent structures. Ischemic stroke predominates, highlighting the need for early MRI and vascular imaging. Recognition of this rare syndrome aids accurate diagnosis and targeted management.