Supranuclear Paralysis of Vertical Gaze

Normal Horizontal Saccades Left

Additional SignsLeft ocular tilt reactionLeft hypotropiaOcular dysmetriaRight gaze to center hypermetricLeft gaze to center hypometricLight-near dissociation of the pupils

Light-near Dissociated Pupils

Figure 1. MRI DWI hyperdensity in the right thalamusextending into the right parasagittal midbrainsurrounding the red nucleus

On follow-up two months later he had:Full vertical gaze with slow saccades upand downOn looking down the eyes lateropulsed tothe left or convergedBeats of convergence nystagmusprovoked by a fast upward saccade andPersistent somnolence. He has adoptedthe habit of setting 3 alarm clocks to wakehim each morning

Normal Upgaze

Normal Downgaze

Figure 2A. Axial T2 MRI Chronicright thalamic infarct

Figure 2B. Coronal MRI, Chronicright thalamic infarct

Figure 2C. Sagittal MRI Chronic rightthalamic infarct

Figure 3. Position of the patient’s eyesin (a) straight ahead gaze (b) left gaze(c) right gaze (d) attempted upgaze and(e) attempted downgaze.

Figure 4 T2 axial and diffusion MRI of the midbrain. Thearrows indicate the ischemic lesion at caudal (left) androstral (right) midbrain levels.

Figure 5. Histologic cross-section at caudal (left) androstral (right) midbrain levels showing structures involvedin the mediation of vertical gaze. PC, posteriorcommissure; PUL, pulvinar nucleus of the thalamus; SC,superior colliculus; PG, periaqueductal gray; RN, rednucleus; SN, substantia nigra; 3 rd nuc, this cranial nervenucleus; Int Caps, Internal capsule; rlMLF, rostralinterstitial nucleus of the medial longitudinal fasciculus;INC, interstitial nucleus of Cajal.

Neurology 38(1): 114-22; 1985

ReferencesAlemdar M, Kamaci MD, Budak F.Unilateral midbrain infarction causingupward and downward gaze palsy. J Neur-Ophthalmol 2006; 26:173-176.Percheron G. Les arteres du thalamushumain. Il Arteres et therritoresthalamiques paramedians de l’arterebasilair communicante. Rev Neurol 1976;132:309-324.

Ranalli PJ, Sharpe JA, Fletcher WA. Palsyof upward and downward saccadic, pursuitand vestibular movements with a unilateralmidbrain lesion: pathophysiologiccorrelations. Neurol 1988; 38(1): 114-22.Trojanowski JQ, Wray SH. Vertical gazeopthalmoplegia: selective paralysis ofdowngaze. Neurology 1980; 30:605-610.

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