Millard-Gubler syndrome is a brainstem syndrome following damage to the caudal portions of the pons. The most common cause of this phenomenon is stroke. Characteristic of brainstem syndromes is crossed paralysis symptomatology, which is mainly treated with physiotherapy.
What is Millard-Gubler syndrome?
The human brainstem is composed of the parts of the brain below the diencephalon. Excluding the cerebellum, it is the midbrain and rhomboid brain including the associated structures cerebral peduncle, midbrain dome, midbrain roof, bridge, and medulla oblongata. Damage to brainstem-involved structures is associated with functional impairment of motor function and is also referred to as brainstem syndromes. Depending on the exact localization of damage, different brainstem syndromes are distinguished, the common feature of which is a crossed paralysis symptomatology. One of the midbrain syndromes is Millard-Gubler syndrome. This disease is named after its first descriptors, the French physicians Millard and Gubler. The first description is dated from the 19th century. Because of the localization of damage and symptoms, Millard-Gubler syndrome is also known in the literature as caudal bridge foot syndrome or abducens facialis syndrome. It is also sometimes referred to as Raymond-Foville syndrome.
Causes
Like all brainstem syndromes, Millard-Gubler syndrome is due to damage to the brainstem region. Most often, this damage occurs as part of a stroke. In Millard-Gubler syndrome, the primary cause is usually a stroke within the vertebral artery stroma. In the caudal portions of the bridge (pons), this event damages the nucleus nervi facialis, the core area of the facial nerves. In the immediate vicinity of this region, the abducens nerve exits, which is also affected by the ischemic stroke processes. In addition, the pyramidal tracts are affected by the damage. Although stroke is considered the most common cause of Millard-Gubler syndrome, other disease events may also be considered as primary causes. Tumors in the caudal bridge region are just as conceivable as bacterial or autoimmunological inflammations. Much less frequently, mechanical damage after accidents is responsible for the clinical picture.
Symptoms, complaints, and signs
Like all brainstem syndromes, Millard-Gubler syndrome is characterized by crossed paralysis symptoms. Crossed in this context refers to the involvement of both sides of the body. In principle, the left side of the brain controls the right side of the body and vice versa. However, this only applies from the pyramidal pathway crossing close to the spinal cord. For example, the facial nerves exit on the same side of the body where they are connected to the brain. In crossed paralysis symptomatology, both the facial nerves on the side of the brain injury and the nerves originating from the spinal cord on the opposite side of the brain injury are affected. In Millard-Gubler syndrome, facial nerve paresis and abducens paresis occur on the side of the damage for this reason. On the opposite side, spastic hemiplegia occurs due to pyramidal tract involvement. Spastic in this context means that the muscles of the paralyzed side show increased tone and, for this reason, the limbs can only be moved to a limited extent or not at all.
Diagnosis and course of the disease
The physician makes the diagnosis of Millard-Gubler syndrome based on clinical symptoms. To confirm the tentative diagnosis, he orders an imaging procedure such as MRI of the head. In the caudal bridge region of the brainstem, the slice images show the primary causative brain damage. MRI can also be used for fine diagnosis. Tumors, for example, show a particularly characteristic image in the slice image that is clearly distinguishable from inflammatory and ischemia-related brain damage. In case of doubt, an additional CSF analysis cannot take place. For this purpose, a sample of cerebrospinal fluid is taken from the external CSF space and given to the laboratory. Bacterial, autoimmunological and tumor-related disease processes within the brain often alter the composition of the cerebrospinal fluid in specific ways.The prognosis for patients with Millard-Gubler syndrome depends on the extent of damage and the treatability of the primary cause of damage.
Complications
Millard-Gubler syndrome results in paralysis of the patient’s body, which can occur in a variety of locations. Especially in the face, the paralysis and disturbances of sensitivity can be very unpleasant, leading to significant limitations in the patient’s life. It is not uncommon for those affected to then be dependent on the help of other people in their daily lives and can no longer perform certain activities on their own. The intake of food and liquids may also be restricted, so that Millard-Gubler syndrome leads to a severe reduction in the patient’s quality of life. Movement restrictions also occur and the affected person suffers from muscle weakness and fatigue. The treatment of Millard-Gubler syndrome is usually causal and is primarily based on the underlying disease that is responsible for these symptoms. If it is a tumor, it may have spread to other areas of the body. Furthermore, those affected are usually also dependent on physiotherapy. Whether there is a reduction in life expectancy can usually not be predicted in general.
When should you see a doctor?
Because Millard-Gubler syndrome is a congenital condition and cannot be self-healing, a doctor must always be consulted for this complaint. Without treatment, the symptoms of Millard-Gubler syndrome can significantly complicate the life of the affected person. A doctor should usually be consulted if the patient suffers from symptoms of paralysis, which can occur in different parts of the body. Often, one entire side of the patient’s body is paralyzed, leaving the patient unable to move that side. Likewise, Millard-Gubler syndrome can lead to spastic disorders, so that the limbs can only be moved to a very limited extent. If these symptoms occur, a doctor should always be consulted. Diagnosis and detection of Millard-Gubler syndrome usually requires an MRI scan of the head, so this disease cannot be detected by a general practitioner. The patient’s life expectancy is usually not negatively affected by the disease, but it also has limited treatability.
Treatment and therapy
Therapy is given to patients with Millard-Gubler syndrome depending on the primary cause. For acute inflammation, conservative drug treatment is used. Autoimmune inflammation is countered with cortisone. In addition, patients with autoimmune diseases such as multiple sclerosis receive long-term therapy with immunosuppressants designed to weaken the immune system and thus dampen future inflammation. Bacterial inflammations in the context of Millard-Gubler syndrome are in turn brought to healing by means of antibiotics as soon as the type of causative pathogen has been determined. If tumors have caused the symptoms, surgery for excision is performed as far as possible. Depending on the degree of malignancy, concomitant drug therapy or radiation therapy may be required. Inoperable tumors are also treated via these measures. If a stroke has caused the syndrome, stroke prevention is performed immediately to reduce the risk of future ischemia. Regardless of the cause, symptomatic treatment takes place in Millard-Gubler syndrome in addition to the therapeutic steps mentioned above. Because the brain is home to highly specialized tissue, the regenerative capacity in brain tissue is severely limited. This means that damage to brain tissue is irreparable. However, redistribution of brain functions from defective areas to healthy areas in the neighborhood has been observed, especially in stroke patients. In order to support this redistribution, patients with Millard-Gubler syndrome receive physiotherapy and, if necessary, speech therapy, as well as targeted access to the functions of the damaged areas together with specialists. The brain can thus be induced to redistribute.
Outlook and prognosis
Due to the disease, affected individuals suffer from various mental and physical ailments. As a result, the quality of life is significantly reduced. Affected persons are permanently dependent on the help and support of relatives.Simple activities can no longer be performed independently. For this reason, severe depression and other mental illnesses often occur. The movement and coordination of affected persons is also impaired. Speech disorders, paralysis and disturbances in sensitivity can occur. Affected individuals often suffer from dizziness. Paralysis of the tongue may also occur. Affected persons can then no longer take in food or liquids independently. Artificial feeding may be required to prevent the body from becoming undersupplied. Due to the disease and the suffering of the affected person, relatives may also suffer from severe depression and other mental illnesses. It cannot be said whether there will be a positive course of the disease after treatment. It is therefore possible that sufferers will have to spend their entire lives dealing with the symptoms. The life expectancy of affected persons is usually only reduced if the tumor cannot be removed. In other cases, the disease has no effect on the life expectancy of affected individuals.
Prevention
Preventive measures in the context of Millard-Gubler syndrome are limited to stroke prevention. In addition to focusing on healthy diet and adequate exercise, risk factors such as tobacco use are minimized as much as possible as part of stroke prevention.
Follow-up
Millard-Gubler syndrome can lead to serious complications or discomfort in the affected person and must therefore be treated by a physician in any case. In this process, there can also be no independent healing, so the patient is always dependent on treatment by a physician in this case. In most cases, this syndrome causes severe paralysis of the affected person. The paralyses can affect different parts of the body and have a very negative effect on the quality of life of the affected person. This leads to significant restrictions in the daily life of the affected person, so that most patients are dependent on the help and support of friends or their own family. Not infrequently, Millard-Gubler syndrome can also lead to severe depression or other psychological upsets in the relatives. There is severe paralysis in the muscles, so that the patients can no longer move independently. The paralyses often occur on only one side of the body. In some cases, the disease can also cause mental discomfort, so that those affected sometimes suffer from reduced intelligence as a result of Millard-Gubler syndrome.
Here’s what you can do yourself
What measures affected individuals can take themselves depends on the cause and severity of the condition. Acute inflammation is usually treated with medication, supported by bed rest and sparing. Medication is also the best choice for autoimmunological inflammation. The most important self-help measure lies in documenting the effects of the medications and thus smelling out an optimal setting of the respective agent. In case of serious complications, the physician should be informed. If Millard-Gubler syndrome occurs as a result of tumor disease, surgery is required. Sufferers can best support the surgery by following the diet suggested by the doctor before the surgery. A balanced diet supports the immune system and contributes to the healing process. After surgery, rest is also the order of the day. Radiation therapy is also best survived by avoiding stressing the body as much as possible. Symptomatic treatment is necessary to accompany these measures. Neurological damage can be corrected by physiotherapy and, if necessary, speech therapy. Therapeutic counseling is particularly useful when Millard-Gubler syndrome has caused severe brain damage that has a lasting impact on the patient’s quality of life and well-being.
