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Table of Contents    
Year : 2017  |  Volume : 65  |  Issue : 5  |  Page : 1157

"Round the Houses” sign and apraxia of eyelid opening in a 62-year old man

Department of Neurology, Plymouth Hospital NHS Trust, Devon, United Kingdom

Date of Web Publication6-Sep-2017

Correspondence Address:
Shakya Bhattacharjee
Flat 96,21, Plymbridge Lane, Plymouth, PL68AX
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/neuroindia.NI_46_17

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How to cite this article:
Bhattacharjee S, Ng KL. "Round the Houses” sign and apraxia of eyelid opening in a 62-year old man. Neurol India 2017;65:1157

How to cite this URL:
Bhattacharjee S, Ng KL. "Round the Houses” sign and apraxia of eyelid opening in a 62-year old man. Neurol India [serial online] 2017 [cited 2020 Apr 1];65:1157. Available from:

A 62-year old gentleman presented with poor mobility and multiple falls. He demonstrated hypophonic voice, more axial than peripheral rigidity, bilateral upper limb bradykinesia, and postural instability. He also had reduced blinking, eyelid opening apraxia, and impaired horizontal and vertical gaze with “Round the Houses” sign during the vertical saccade testing [Video 1; Supplementary Video]. Magnetic resonance imaging (MRI) of the brain was unremarkable. He was diagnosed with progressive supranuclear palsy (PSP) based on the history and clinical signs.

The “Round the Houses” sign means the inability to produce vertical saccades along the midline. The eyes move vertically in a lateral or oblique (⧚ instead of ⇵) arc to accomplish the movement. This sign adopts the plural form “Houses” as an analogy to each eye making a round excursion in its own “house” (each orbit).

This sign denotes severe cell loss or dysfunction in the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF).[1] The rMLF contains neurons that are responsible mainly for triggering vertical saccades; and, the paramedian pontine reticular formation contains neurons predominantly responsible for generating the horizontal saccades. The “Round the Houses” sign was classically described as an early indicator of the supranuclear gaze pathways dysfunction in PSP.[2],[3] The ophthalmological examination in PSP also shows square wave jerks, lead opening apraxia, and horizontal gaze palsy.[4] Recently, the sign was described in Neimann–Pick disease type C (NPC).[3] However, adult-onset NPC additionally shows facial dystonia, facial grimacing, but no  Parkinsonism More Details, hepatosplenomegaly, and significantly less involvement of horizontal saccades.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Vinny PW, Lal V. Gaze disorders: A clinical approach. Neurol India 2016:64:121-8.  Back to cited text no. 1
Quinn N. The “Round the houses” sign in progressive supranuclear palsy. Ann Neurol 1996;40:951.  Back to cited text no. 2
Eggink H, Brandsma R, Vander Hoeven JH, Lange F, de Koning TJ, Tijssen MA. Teaching Video NeuroImages: The “round the houses” sign as a clinical clue for Niemann-Pick disease type C. Neurology 2016;86:19e202.  Back to cited text no. 3
Mitra K, Gangopadhaya PK, Das SK. Parkinsonism plus syndrome – A review. Neurol India 2003:51:183-8.  Back to cited text no. 4


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