The Lesions Producing Paralysis of Downward But Not Upward Gaze

Jacobs, Lawrence; Anderson, Paul J.; Bender, Morris B.

doi:10.1001/archneur.1973.00490230055007

Cited by 73 publications

(20 citation statements)

References 15 publications

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“…11 We found that classic Weber's syndrome was present in 2 patients with isolated mesencephalic infarct, whereas other patients with multiple infarcts having third-nerve involvement and hemiparesis in the posterior circulation had additional clinical symptoms of thalamic infarct and PCA or SCA territory involvement. In addition to ocular motor disorders, we observed upgaze or downgaze palsy, [32][33][34][35] horizontal and vertical one-and-a-half syndrome, 8 internuclear ophthalmoplegia, 36 -38 skew deviation, 39 and ocular bobbing, 13 but we did not note isolated extrinsic third-nerve palsy, which can mimic diabetic thirdnerve palsy. 40,41 Vertical gaze impairment is a specific localizing neurological symptom suggesting a lesion in the dorsal upper midbrain.…”

Section: Kumral Et Al Mesencephalic and Associated Infarcts 2229mentioning

confidence: 86%

Mesencephalic and Associated Posterior Circulation Infarcts

Kumral

Bayülkem

Akyol

et al. 2002

Stroke

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Background and Purpose-The purposes of this study were to evaluate and review the risk factors and clinical features of patients with posterior circulation stroke involving mesencephalon and neighboring structures and to describe the clinical syndromes according to the mesencephalic arterial territory involved. Methods-We studied all patients with acute posterior circulation stroke involving mesencephalon who were admitted consecutively to our stroke unit over a 6-year period. We selected these patients (3%) from 1296 patients with posterior circulation infarct. Neurological and radiological investigations, including MRI and angiography, were performed in all cases. We classified patients into 4 groups on the basis of MRI findings: (1) isolated mesencephalic infarcts (9 patients); (2) distal territory infarcts (19 patients), including mesencephalon, thalamus, medial temporal and occipital lobes, and cerebellum; (3) middle territory infarcts (12 patients), including the pons and anterior inferior cerebellar artery territory; and (4) proximal territory infarcts (1 patient), including the medulla and posterior inferior cerebellar artery territory. Results-Middle mesencephalon involvement was the most common in all groups, and the anteromedial territory was frequently affected, depending on the direct perforators of basilar artery. In patients with isolated mesencephalic infarct, the clinical picture was dominated by nuclear or fascicular third-nerve palsy and contralateral motor deficits. The distal territory involvement was the most common and associated with consciousness disturbances, gait ataxia, ocular motor disturbances, and visual field deficits. The neurological picture of middle territory infarcts was dominated by consciousness disturbances with dysarthria, horizontal ocular motor disorders, and hemiparesis. Proximal territory involvement was rare and associated with acute unsteadiness, vertigo, dysphagia, dysphonia, tetra-ataxia, and motor weakness. The most common cause of stroke was large-artery disease in 16 patients (39%), cardioembolism in 8 (20%), and small-artery disease with lacunar mesencephalic infarct in 10 (24%). Bilateral mesencephalic infarcts were not uncommon (27%), mainly in patients with multiple and extended infarcts in the posterior circulation, and were associated with poor outcome compared with unilateral infarct. Conclusions-Our study highlights the topographic and clinical heterogeneity of the acute posterior circulation infarcts involving mesencephalon. The variety of the underlying potential causes of stroke requires detailed investigations of the extra and intracranial arteries and the heart.

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Section: Kumral Et Al Mesencephalic and Associated Infarcts 2229mentioning

confidence: 86%

Mesencephalic and Associated Posterior Circulation Infarcts

Kumral

Bayülkem

Akyol

et al. 2002

Stroke

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“…All previous cases of downward gaze palsy examined by necropsy had bilateral lesions located dorsomedial to the red nuclei with variable rostral and caudal extensions [3, 4, 5, 6, 7]. …”

Section: Discussionmentioning

confidence: 99%

Downward Gaze Palsy Caused by Bilateral Lesions of the Rostral Mesencephalon

Ōhashi

Nakano²,

Harada³

et al. 1998

Ophthalmologica

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A 55-year-old man with diabetes mellitus developed diplopia and experienced difficulty in moving his eyes in the vertical plane, especially downward. Horizontal movement of each eye was normal with exotropia. Magnetic resonance imaging revealed small and high signals on both sides of the midbrain near the interstitial nucleus of Cajal (INC). Based upon the recent experimental evidence, we speculate that bilateral lesions involving the INC may have caused downward gaze palsy in our patient.

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“…By contrast, ocular torsion produced by neurochemical lesions of the INC is consistent with the tonic properties of INC neurons and the essential role of the INC in the integration of eye-velocity signals into eye-position signals for both vertical and torsional eye movements (Anderson, 1981;Fukushima et al, 1992a,b). Clinically, however, lesions at the thalamomesencephalic junction produce isolated or combined supranuclear monocular or binocular paralysis of upgaze and/or downgaze (Christoff, 1974;Cogan, 1974;Lessell, 1975;Halmagyi et al, 1978;Jacobs et al, 1978;Trojanowski and LaFontaine, 1981;Pierrot-Deseilligny et al, 1982;Bogousslavsky and Regli, 1984;Ford et al, 1984;Bogousslavsky and Meienberg, 1987;Ranalli et al, 1988;Deleu et al, 1989;Bogousslavsky et al, 1990;Hommel and Bogousslavsky, 1991;Thomke and Hopf, 1992;Green et al, 1993). The existence of separate upgaze and downgaze deficits suggests that an intrinsic arrangement of vertical upward and downward premotor saccadic neurons may exist within the riMLF.…”

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confidence: 99%

Spatial organization of premotor neurons related to vertical upward and downward saccadic eye movements in the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) in the cat

Wang

Spencer

1996

J. Comp. Neurol.

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The rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) contains premotor neurons that are related to the control of vertical and torsional saccadic eye movements. In the present study, complimentary light microscopic anterograde biocytin and retrograde horseradish peroxidase experiments have been performed to determine the organization of premotor neurons in the riMLF in the cat that are related intimately to the vertical motoneuron populations in the oculomotor and trochlear nuclei. The results indicate a rostral-caudal topographic arrangement of neurons in the riMLF that is related to the target projections to vertical downward (inferior rectus and superior oblique) and vertical upward (superior rectus and inferior oblique) motoneurons, respectively, in the oculomotor and trochlear nuclei. Both the anterograde and the retrograde studies are consistent, in that they demonstrate the tendency for downward and upward riMLF neurons to be separated spatially by a distance of approximately 0.5 mm in the rostral-caudal axis of the nucleus. The riMLF projections to inferior oblique and superior oblique motoneurons are predominantly ipsilateral. Projections to inferior rectus and superior rectus motoneurons, however, are bilateral, and, presumably, they provide one means for assuring the conjugacy of vertical saccadic eye movements. Because premotor burst neurons that encode parameters for upward or downward saccades are intermingled within the riMLF, and excitatory and inhibitory premotor neurons also coexist in this region, the findings from this study suggest that subregions of the riMLF contain coexistent populations of excitatory and inhibitory neurons that are related to opposite directions of vertical eye movements. The spatial segregation of excitatory premotor neurons in the riMLF that are related to vertical upward vs. downward movements, furthermore, provides a basis for the interpretation of vertical upward and/or downward gaze palsies that might result from discrete lesions at the mesodiencephalic junction in humans.

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The Lesions Producing Paralysis of Downward But Not Upward Gaze

Abstract: given the simple command "look down" (Fig 1, right) (Fig 2, A), and during oculocephalic maneuvers in the midsagittal plane to induce downward movement of the eyes (Fig 2,B). However, each of the EOG recordings showed that a full range of upward eye movement was possible (Fig 2,A and

Cited by 73 publications

References 15 publications

Mesencephalic and Associated Posterior Circulation Infarcts

Mesencephalic and Associated Posterior Circulation Infarcts

Downward Gaze Palsy Caused by Bilateral Lesions of the Rostral Mesencephalon

Spatial organization of premotor neurons related to vertical upward and downward saccadic eye movements in the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) in the cat

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