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Selective paralysis of downward gaze caused by bilateral lesions of the mesencephalic periaqueductal gray matter

Lawrence Jacobs, Dent Neurologic Institute. Buffalo, NY, and the Departments of Neurology and Physiology (Neurobiology) of the State University of New York School of Medicine at Buffalo; Reid R. Heffner Jr., Erie County Medical Center and the Department of Pathology, State University of New York at Buffalo: and Richard P. Newman, Dent Neurologic Institute, Buffalo, NY.

A patient who had selective paralysis of downward gaze caused by bilateral lesions of the dorsolateral mesencephalic periaqueductal gray (PAG) matter is reported. Her necropsy findings differed from all previous reports of the syndrome, in that regions of the mesencephalon that have been considered as critical for executing downward gaze (dorsomedial to red nuclei, rostral interstitial nuclei of the medial longitudinal fasciculus [ri MLF]) were normal. These lesions may have produced the syndrome by involving the caudal portions of the nuclei of the posterior commissure (subcommissural), from which one of the commissural systems used by the ri MLF originates. It is also possible that the syndrome was produced by selective destruction of PAG neurons that generate downward impulses or by interruption of posterior commissure fibers containing downward impulses that travel through the dorsolateral PAG before terminating in the more ventral mesencephalon.

Address correspondence and reprint requests to Dr. Jacobs, Dent Neurologic Institute, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209.

Supported in part by grants from Delaware North Companies and the Dent Family Foundation, Buffalo, NY.

Presented in part at the thirty-sixth Annual Meeting of the American Academy of Neurology, Boston, MA, April 1984.

Accepted for publication July 30, 1984.

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