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Palsy of upward and downward saccadic, pursuit, and vestibular movements with a unilateral midbrain lesion

Pathophysiologic correlations

Neuro-ophthalmology Unit, Division of Neurology, the Playfair Neuroscience Unit, The Toronto Hospital, and the Departments of Medicine and Ophthalmology, University of Toronto, Toronto, Ontario, Canada.

Upward and downward gaze palsy was measured by a magnetic search coil technique and correlated with neuropathologic findings in a patient with a unilateral midbrain infarct. Oculography demonstrated (1) saccadic palsy above primary position and slow, limited vertical saccades below; (2) low-gain, restricted vertical pursuit; and (3) low-gain, abnormal phase lead, and restricted range of the vertical vestibulo-ocular reflex (VOR). Bidirectional palsy of vertical saccades is attributed to unilateral loss of burst cells in the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) and interruption of burst cell fibers from the opposite riMLF. Pathways mediating vertical pursuit and integration of the vertical VOR also traversed the infarct, which included the interstitial nucleus of Cajal.

Address correspondence and reprint requests to Dr. Sharpe, Division of Neurology, The Toronto Hospital, 399 Bathurst Street, Toronto, Ontario, M5T 2S8 Canada.

Supported by Medical Research Council of Canada grants ME5509 and MT5404 (Dr. Sharpe), a Medical Research Council of Canada Fellowship in Neuro-ophthalmology (Dr. Ranalli), and the Alberta Heritage Foundation for Medical Research (Dr. Fletcher).

Presented in part at the thirty-eighth annual meeting of the American Academy of Neurology, New Orleans, LA, April 1986.

Received January 7, 1987. Accepted for publication in final form March 17, 1987.

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