Conjugate upward gaze paralysis with unilateral ptosis caused by a unilateral midbrain infarction

Acute esotropia, convergence-retraction nystagmus and contraversive ocular tilt reaction from a paramedian thalamomesencephalic infarct

“…These mechanisms could account for the acute esotropia, convergence-retraction nystagmus and enophthalmos during adduction in our patient. The contralateral vertical gaze paresis and partial ptosis were attributed to the involvement of the rostral interstitial medial longitudinal fasciculus, the interstitial nucleus of cajal (INC) and the nucleus of the posterior commissure system which projects its axons, through the medial longitudinal fasciculus, to the oculomotor complex 2. The contraversive OTR is most likely due to ischaemia of the INC 3…”

Midbrain infarction presenting with binocular elevation palsies and ptosis

“…There was one case of isolated upgaze palsy that did not affect the downgaze [5], but the patient presented with hemiparesis and fluctuations in consciousness. In addition, supranuclear gaze palsy may be associated with other ocular motor symptoms, such as vertical gaze-evoked nystagmus, pursuit abnormalities, and VOR impairment [5]. Another patient with isolated upgaze paralysis had a single lesion of the midbrain confined to the dorsal periaqueductal gray matter between the levels of the superior and inferior colliculi [6].…”

“…We found several reports of midbrain [4][5][6]. However, pure upgaze palsies due to supranuclear lesion were rare.…”

“…However, pure upgaze palsies due to supranuclear lesion were rare. There was one case of isolated upgaze palsy that did not affect the downgaze [5], but the patient presented with hemiparesis and fluctuations in consciousness. In addition, supranuclear gaze palsy may be associated with other ocular motor symptoms, such as vertical gaze-evoked nystagmus, pursuit abnormalities, and VOR impairment [5].…”