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NEUROIMAGES
Year : 2019  |  Volume : 67  |  Issue : 1  |  Page : 331

Ocular ipsipulsion elicited by closing eyes in lateral medullary infarction


1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, PR China
2 Department of Emergency, Huashan Hospital, Fudan University, Shanghai, PR China

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Qiang Dong
Department of Neurology, Huashan Hospital, No. 12, Wulumuqi Road (M), Jing'an District, Shanghai 200040
PR China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.253618

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How to cite this article:
Yang SL, Yang T, Han X, Dong Q. Ocular ipsipulsion elicited by closing eyes in lateral medullary infarction. Neurol India 2019;67:331

How to cite this URL:
Yang SL, Yang T, Han X, Dong Q. Ocular ipsipulsion elicited by closing eyes in lateral medullary infarction. Neurol India [serial online] 2019 [cited 2019 Mar 20];67:331. Available from: http://www.neurologyindia.com/text.asp?2019/67/1/331/253618


An 86-year-old man presented to the emergency room complaining of sudden onset of vertigo. Neurological examination showed a primary position left-beating nystagmus, decreased sensation of pain and temperature in the left limbs, and right Horner's syndrome. Extraocular movement was full in all directions. When he was asked to close his eyes, the eyes deviated to the extreme right lateral position; when he opened his eyes, they turned towards mid-position [Video 1]. He could perform right gaze effortlessly, but left gaze required effort. Saccades towards the right side were hypermetric and saccades towards the left side were hypometric [Video 1]. Right gaze deviation was also unveiled by computed tomography (CT) scan [Figure 1]a. Magnetic resonance imaging (MRI) showed restricted diffusion in right lateral medulla, confirming the diagnosis of acute lateral medullary infarction, also known as Wallenberg's syndrome [Figure 1]b.
Figure 1: (a) Right gaze deviation appeared during a computed tomography scan in the absence of visual fixation. Note that the position of the junction of eyeballs and optic nerves (arrows) demonstrated an ocular right deviation. (b) Magnetic resonance imaging showed restricted diffusion in the right lateral medulla, suggestive of an acute infarction

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Ocular ipsipulsion, a unique sign of a lateral medullary lesion, manifests as a tonic deviation of eyes toward the damaged side despite the presence of full extraocular movements.[1] It should be distinguished from conjugate gaze palsy, the inability to move both eyes in the same direction, which is associated with lesions in the pons or frontal lobe. Ocular ipsipulsion is most prominent when visual fixation is interrupted,[1] for example, when eyes are closed or during the performance of a CT scan, as seen in our case. Despite being a sign with localizing value, it is often overlooked in patients with lateral medullary infarction.

The mechanism of ocular ipsipulsion has not been well elucidated. It is believed that ocular ipsipulsion results from interruption of the contralateral olivocerebellar pathways passing through the ipsilateral inferior cerebellar peduncle. Due to loss of inhibitory signal from the ascending fibers, Purkinje cell projections increase activity to inhibit the ipsilateral vestibular nuclei. As a result, the predominant activity of the contralateral vestibular nuclei generates a slow-phase drift towards the side of lesion.[2]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Meyer KT, Baloh RW, Krohel GB, Hepler RS. Ocular lateropulsion. A sign of lateral medullary disease. Arch Ophthalmol 1980;98:1614-6.  Back to cited text no. 1
    
2.
Solomon D, Galetta SL, Liu GT. Possible mechanisms for horizontal gaze deviation and lateropulsion in the lateral medullary syndrome. J Neuro Ophthalmol 1995;15:26-30.  Back to cited text no. 2
    


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