Eight-and-a-Half Syndrome as The First Presentation of Unknown Metastatic Primary Tumor |Biomedgrid

The eight-and-a-half syndrome (EHS) is a rare brainstem syndrome. We present a case of a 48-year-old man with a 5-day history of visual disturbance, headache and dizziness of sudden onset concomitantly with a unique presentation of a conjugate horizontal gaze palsy, an ipsilateral internuclear ophthalmoplegia and an ipsilateral lower motor neuron-like facial palsy. Magnetic resonance imaging revealed several lesions of nodular morphology, with hypersignal in T2 and FLAIR, with signal reinforcement after gadolinium administration (complete ring morphology). A Thoracic CT revealed a lesion with spiculate contours on the right lower lobe together with a right perihilar and mediastinal infiltrative lesion and a large pre-tracheal, infracarinal adenopathic conglomerate. An aspiration biopsy of left axillary nodes allowed the diagnosis of small-cell lung cancer (SCLC), staged as cT4N3M1c–IVB. Treatment with corticosteroid therapy as well as holocranial radiotherapy for the brain metastases and chemotherapy was started, with progressive improvement and total resolution of EHS after one month of treatment. This is the first case describing an EHS as the initial clinical presentation of brain metastases. The authors would like to highlight the importance of recognizing the EHS as the first presentation of a serious non-neurological primary disease that needs urgent multidisciplinary guidance.