Eyelid retraction, pseudoabducens and upgaze palsy due to a mesodiencephalic hemorrhage

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Identifier Dorsal_midbrain_Colliers_and_pseudoabducens
Title Eyelid retraction, pseudoabducens and upgaze palsy due to a mesodiencephalic hemorrhage
Subject OMS Mesenecephalon, Convergence Reaction Nystagmus, Upgaze Palsy, Abnormal Range, Sixth Nerve Palsy, Vertical Gaze Palsy, Eyelid Retraction, OMS Dorsal Midbrain
Creator Jiaying Zhang, MD, Department of Neurology The Johns Hopkins School of Medicine ; Amir Kheradmand, MD, Departments of Neurology, Otolaryngology - Head & Neck Surgery The Johns Hopkins School of Medicine; Daniel R. Gold, DO, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, The Johns Hopkins School of Medicine
Description This is a 70-yo-man who suffered a right midline thalamic/rostral midbrain hemorrhagic stroke causing a pretectal (Parinaud's) syndrome. There was prominent eyelid retraction (Collier's sign), a left pseudo-abducens, and upgaze palsy with convergence retraction nystagmus. There was no light-near dissociation. Eyelid retraction is thought to be related to damage of the the M-group, which is adjacent to the riMLF (generates vertical and torsional saccades). The M-group sends projections to the central caudal nucleus (i.e., where the fibers that will innervate the levator palpebrae muscles originate) and superior rectus and inferior oblique subnuclei. Disruption of these pathways can lead to eyelid retraction, thought to be related to a dissociation between eye position and eyelid position, where the brain perceives that the eyes are higher than they actually are. One theory is that this represents an overactivation of the M-group in an effort to overcome an upgaze palsy. ; His abduction paresis OS was thought to represent a "pseudoabducens" palsy in the absence of pontine ischemia and given his mesodiencephalic hemorrhage, a localization that is often associated with contralateral pseudoabducens due to presumed disinhibited pathways and overaction of the medial rectus muscle. When the vergence pathways are affected rostrally (as in this case), pseudoabducens palsies tend to be contralateral. When the vergence pathways are affected more caudally in the midbrain, they tend to be ipsilateral. Despite his abduction paresis being due to a presumed "supranuclear" etiology, it was not clearly overcome by VOR, although this has been previously described. There was also no clear abduction lag OS with saccades. ; For an explanation of CRN/upgaze paresis in the Parinaud's syndrome, see video "Parinaud's in a man with glioblastoma multiforme of the pineal gland."
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Type Image/MovingImage
Format video/mp4
Rights Management Copyright 2017. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Language eng
ARK ark:/87278/s6797vq6
Setname ehsl_novel_gold
Date Created 2017-05-31
Date Modified 2018-05-25
ID 1251075
Reference URL https://collections.lib.utah.edu/ark:/87278/s6797vq6