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Table of Contents    
LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 170-173

Bilateral vertical gaze palsy in unilateral mesodiencephalic junction lesion: A case series


1 Department of Neurology, Neuropsychological, Morphological and Movement Sciences, Section of Clinical Neurology, University of Verona; Department of Neurology, Franz Tappeiner Hospital, Meran, Italy
2 Department of Neurology, Franz Tappeiner Hospital, Meran, Italy
3 SSO Stroke Unit, UO di Neurologia, DAI di Neuroscienze e Istituto di Neurochirurgia, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
4 Department of Neurology, Franz Tappeiner Hospital, Meran, Italy; Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
5 Parmanand Deepchand Hinduja National Hospital, Mumbai, India

Date of Submission07-Dec-2012
Date of Decision07-Dec-2012
Date of Acceptance10-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Francesco Brigo
Department of Neurology, Neuropsychological, Morphological and Movement Sciences, Section of Clinical Neurology, University of Verona; Department of Neurology, Franz Tappeiner Hospital, Meran, Italy

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111131

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How to cite this article:
Brigo F, Lochner P, Tomelleri G, Moretto G, Nardone R, Gursahani R. Bilateral vertical gaze palsy in unilateral mesodiencephalic junction lesion: A case series. Neurol India 2013;61:170-3

How to cite this URL:
Brigo F, Lochner P, Tomelleri G, Moretto G, Nardone R, Gursahani R. Bilateral vertical gaze palsy in unilateral mesodiencephalic junction lesion: A case series. Neurol India [serial online] 2013 [cited 2019 Dec 15];61:170-3. Available from: http://www.neurologyindia.com/text.asp?2013/61/2/170/111131


Sir,

Conjugate bilateral vertical gaze palsy (VGP) is a clinical feature of lesions involving the mesodiencephalic junction (MDJ), where anatomical structures for vertical gaze control are located. [1] VGP occurring after unilateral mesodiencephalic lesions has been rarely described. [1],[2],[3],[4],[5] We report three additional patients with strokes at the right MDJ sparing the posterior commissure (PC), and resulting in conjugate bilateral VGP. This case series confirms that a conjugate bilateral combined up- and down-gaze VGP may also occur following a unilateral lesion of MDJ sparing the PC. Clinical features and neuroimaging findings of the patients are reported in the [Table 1]. The three patients described here presented with acute onset of vertical diplopia and were found to have bilateral conjugate VGP involving both up- and down-gaze. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Figure 6]
Figure 1: Brain magnetic resonance imaging, axial FLAIR: Patient 1. Right medial thalamic ischemic lesion (a) extending to rostral mid-brain; (b) and involving right riMLF and the INC but sparing the PC

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Figure 2: Picture of patient 2 showing a right trochlear nerve involvement associated with VGP

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Figure 3: Brain magnetic resonance imaging, coronal FLAIR: Patient 1. Right medial thalamic ischemic lesion extending to rostral mid-brain

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Figure 4: Brain magnetic resonance imaging, axial T2 - weighted images: Patient 2. Right medial thalamic ischemic lesion (a) extending to rostral mid-brain; (b and c), involving right riMLF and the INC but sparing the PC

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Figure 5: Brain magnetic resonance imaging, coronal FLAIR and sagittal T1: Patient 2: Right medial thalamic ischemic lesion extending to rostral mid-brain

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Figure 6: Axial CT head scan. Patient 3. Localized small hemorrhagic lesion involving rostral mid - brain, in the region containing right riMLF and the INC, but sparing the PC

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Table 1: Reporting data on patients

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The neural structures and pathways underlying vertical gaze control are yet not fully understood but seem to be largely located in MDJ, rostral mid-brain reticular formation and pretectal area. They include the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF), the interstitial nucleus of Cajal (INC), the nucleus of Darkschewitsch, and the PC with its nuclei. The riMLF, the INC, and the PC are neural structures of the rostral mid-brain reticular formation thought to play a relevant role for the control of vertical gaze [Figure 7] and [Figure 8]. The riMLF is a wing-shape nucleus, lying dorsomedial to the red nucleus and rostral to the oculomotor nuclei. It contains the neural generators for bilateral vertical saccades. Excitatory burst neurons within this nucleus send collaterals to motoneurons supplying yoked muscle pairs of the two eyes. Axon collaterals responsible for upward saccades reach bilaterally the elevator muscles (superior rectus and inferior oblique), crossing within the oculomotor nucleus, whereas collaterals for downward saccades project only to the ipsilateral inferior rectus and superior oblique which act as depressor muscles. [1],[5] The INC, the neural integrator for vertical, and torsional gaze lie close and caudal to the riMLF. It is responsible for the vertical smooth pursuit and vertical vestibular ocular reflexes. Neurons contained in this nucleus contribute to hold the eyes in eccentric gaze after a vertical saccade and in the eye-head coordination in the roll plane. [1],[5] The PC contains the projections from INC to the controlateral oculomotor nuclei and the opposite INC. Furthermore, it contains axons responsible for upgaze originating from the nucleus of the PC and projecting to the riMLF, and to the INC. [1],[5] The final pathways are the motor neurons of the III and IV cranial nerves. The oculomotor nucleus is placed under the superior colliculus beyond which it extends for a short distance into the gray substance in the floor of the III ventricle while the trochlear nucleus is level with the upper part of the inferior colliculus. Although approximate given by the suboptimal resolution of MRI and CT imaging, in these patients it is possible to perform a correlation between clinical features, brain injuries (as shown by imaging tests), and anatomical pathways. Our three patients are consistent with previous published reports [2],[3],[4],[5] and definitively illustrate that VGP may be induced by unilateral lesions, which involve not only the ipsilateral riMLF but also the contralateral riMLF fibers after their decussation. It can be assumed that in our patients, a unilateral lesion of right riMLF interrupted the crossing fibers from the left riMLF as they traverse the right mid-brain tegmentum, so inducing an anatomically unilateral, but functionally bilateral lesion.
Figure 7: (a) Brain MRI, axial T2 - weighted images. Normal subject. Transverse section of mid - brain at level of superior colliculi; (b) Transverse section of mid - brain at level of superior colliculi (schematic). From (c) Brain MRI, axial T2 - weighted images. Normal subject. Transverse section of mid - brain at level of mesodiencephalic junction; (d) Brain MRI, axial T2 - weighted images. Normal subject. Transverse section of mid - brain at diencephalic level. White arrow: Medial longitudinal fasciculus. Black arrow: Nucleus of the oculomotor. Short white arrow: Posterior commissure

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Figure 8: Scheme for upward eye movements (left) and downward eye movements (right) in the brainstem. Reproduced from Leigh RJ, Zee DS. The neurology of eye movements, 3rd ed. New York: Oxford University Press, 1999, with permission

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  References Top

1.Bhidayasiri R, Plant GT, Leigh RJ. A hypothetical scheme for the brainstem control of vertical gaze. Neurology 2000;54:1985-93.  Back to cited text no. 1
    
2.Bogousslavsky J, Miklossy J, Regli F, Janzer R. Vertical gaze palsy and selective unilateral infarction of the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF). J Neurol Neurosurg Psychiatry 1990;53:67-71.  Back to cited text no. 2
    
3.Hommel M, Bogousslavsky J. The spectrum of vertical gaze palsy following unilateral brainstem stroke. Neurology 1991;41:1229-34.  Back to cited text no. 3
    
4.Alemdar M, Kamaci S Budak F. Unilateral mid-brain infarction causing upward and downward gaze palsy. J Neuroophthalmol 2006;26:173-6.  Back to cited text no. 4
    
5.Pothalil D, Gille M. Conjugate downward and upward vertical gaze palsy due to unilateral rostral mid-brain infarction. J Neurol 2012;259:779-82.  Back to cited text no. 5
    


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