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Identifier 209-1
Title Lateropulsion
Ocular Movements Deviation of the Eyes Under Closed Lids; Lateropulsion
Creator Shirley H. Wray, M.D., Ph.D., FRCP, Professor of Neurology Harvard Medical School, Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Contributor Primary Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Subject Deviation of the Eyes Under Closed Lids; Lateropulsion; Dorsolateral Medullary Infarction; Medulla Infarct
Supplementary Materials PowerPoint Presentation: Lateropulsion: Shirley H. Wray, M.D., Ph.D., FRCP, Harvard Medical School
Presenting Symptom Unsteady gait
History This 60 year old patient has Wallenberg's syndrome due to infarction of the left dorsolateral medulla. Wallenberg's syndrome is the best recognized syndrome involving the vestibular nuclei and adjacent structures. Unilateral infarcts affecting the vestibular nuclei may produce an oculomotor imbalance manifest by: 1. Spontaneous nystagmus 2. Skew deviation 3. Ocular tilt reaction (OTR) An additional finding - lateropulsion (deviation of the eyes towards the side of the lesion) may occur in darkness, behind closed lids, or with a blink, as in this case. Lateropulsion of saccades may reflect interruption of axons running in the inferior cerebellar peduncle from the inferior olivary nucleus to the cerebellum. Figure 1 shows a hypothetical scheme to account for lateropulsion of saccades. Interruption of climbing fibers originating from the inferior olivary nucleus may occur prior to their crossing in the medulla (1) or as they enter the inferior cerebellar peduncle in Wallenberg's syndrome. (2) Loss of climbing fiber inputs to Purkinje cells in the dorsal vermis causes the latter to inhibit the fastigial nucleus (4), which causes ipsipulsion of saccades. Pharmacological inactivation of the dorsal vermis (3) causes contrapulsion (although clinical lesions produce bilateral hypometria). Interruption of crossed fastigial nucleus outputs in the superior cerebellar peduncle (uncinate fasciculus, (5) causes contrapulsion. Thus contrapulcsion arises at sites 1, 3 and 5 and ipsipulsion at sites 2 and 4. Taken from Leigh RJ, Zee DS. The Saccadic System. Chp 3; 108-187. In: The Neurology of Eye Movements 4th Edition. Oxford University Press, New York 2006 with permission. Also consistent with this scheme is the observation that ipsipulsion of saccades with deviation of the eyes to the side of the lesion can be produced experimentally by lesions of the fastigeal nucleus. For further review of lateropulsion, nystagmus and the OTR see Box 12-1 Ocular Motor Findings in Wallenberg's Syndrome of Dorsolateral Medullary Infarction. Pg. 603 (8). View also ID161-20 - a patient with lateropulsion and multiple sclerosis alongside this case.
Clinical The eye movement clip of this patient is shown courtesy of Dr. Marc Dinkin, Department of Neurology, Brigham & Women's Hospital, Boston. The patient had: • Lateropulsion - (deviation) of the eyes, toward the side of the lesion, under closed lids. • The eyes are conjugately deviated to the right in this patient • On opening the eyes and on blinking there is a fast corrective horizontal saccade to move the eyes to the primary position. • Horizontal nystagmus on gaze to the left • Counter clockwise torsional nystagmus on gaze to the right • Upbeat nystagmus on upgaze • No nystagmus on downgaze • Saccadic pursuit to right > to the left Lateropulsion, an unusual sensation of being pulled toward the side of the lesion, is often a prominent complaint in Wallenberg's syndrome. A variety of unusual sensations of body and environmental tilt may also occur. The description may be so bizarre as to be thought to be psychiatric. For example, the patient may report the whole room tilted on its side or even upside down. One personal case of mine was a truck driver who felt his truck was tilted to the right and he feared it would tip over. He stopped driving and opened the cab door to get out. He expected he would have to jump down 3 or 4 feet to allow for the tilt of the truck. He jumped, and unexpectedly hit the ground. Such misperceptions are usually transient but sometimes reoccur. Smaller tilts of the subjective visual vertical tend to be more persistent. Similar misconceptions of the visual world are occasionally reported in patients without signs of dorsolateral medullary infarction due to a transient brainstem or cerebellar ischemic attack.
Neuroimaging Neuroimaging studies were not available in this patient. Illustrative images in two separate patients one with a medial medullary infarct and the other with a lateral medullary infarction are shown here: Lateral medullary infarction Figure 2 Axial T2WI in a patient with a classic Wallenberg syndrome shows a normal flow void in the left vertebral artery. The right vertebral artery is filled with thrombus which is isointense with brain. Note hyperintensity in the right olive as well as the lateral medulla. A small old infarct is also present in the left cerebellar hemisphere. Right PICA territory infarct. Medial medullary infarct Figure 3 Axial T2WI shows hyperintensity in the olive and medial medulla Figure 4 Axial DWI shows restriction in the same territory Figure 5 MRA shows an occluded left vertebral artery with sparing of the anterior inferior cerebellar artery which arises from the basilar artery above the vertebral artery confluence. Courtesy of Anne Osborn, M.D.
Anatomy Figure 1
Pathology Infarction
Etiology Posterior inferior cerebellar artery occlusion Dorsolateral medullary infarct
Disease/Diagnosis Dorsolateral Medullary Infarction; Wallenberg's syndrome
References 1. Baloh RW, Yee RD, Honrubia V. Eye movements in patients with Wallenberg's syndrome. Ann N Y Acad Sci. 1981;374:600-613. 2. Charles N, Froment C, Rode G Vighetto A, Turjman F, Trillet M, Aimard G. Vertigo and upside down vision due to an infarct in the territory of the medial branch of the posterior inferior cerebellar artery caused by dissection of a vertebral artery. J Neurol Neurosurg Psychiatry 1992;55:188-189. 3. Dietrich, DM, Brandt T. Wallenberg's syndrome: lateropulsion, cyclorotation, and subjective visual vertical in thirty-six patients. Ann Neurol 1992;31:399-408. 4. Hain TC, Zee DS, Mordes M. Blink-induced saccadic oscillations. Ann Neurol 1986;19:299-301. 5. Kameda W, Kawanami T, Kurita K, Daimon M, Kayama T, Hosoya T, Kato T. Lateral and medial medullary infarction: a comparative analysis of 214 patients. Stroke 2004;35:694-699. 6. Kim JS. Pure lateral medullary infarction: clinical radiological correlation of 130 acute consecutive patients. Brain 2003;126:1864-1872. 7. Kommerell G, Hoyt WF. Lateropulsion of saccadic eye movements. Electro-oculographic studies in a patient with Wallenberg's syndrome. Arch Neurol 1973; 28:313-318. 8. Leigh RJ, Zee DS. Chp 10;149; Chp 12;603. The Neurology of Eye Movements 4th Edition. Oxford University Press, New York 2006. 9. Morrow MJ, Sharpe JA. Torsional nystagmus in the lateral medullary syndrome. Ann Neurol 1988;24:390-398. 10. Sacco RL, Freddo L, Bello JA, Odel G, Onesti ST, Mohr JP. Wallenberg's lateral medullary syndrome. Clinical-magnetic resonance imaging correlations. Arch Neurol 1993;50:609-614. 11. Tiliket C, Ventre J, Vighetto A, Grochowicki M. Room tilt illusion - a central otolith dysfunction. Arch Neurol 1996;53:1259-1264.
Relation is Part of 161-21, 207-1
Contributor Secondary Marc Dinkin, M.D., Brigham & Women's Hospital, Boston, 2006 Anne Osborn, M.D. University of Utah Medical Center
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 2006
Type Image/MovingImage
Format video/mp4
Source VHS
Rights Management Copyright 2002. For further information regarding the rights to this collection, please visit:
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
Language eng
ARK ark:/87278/s6qn94b4
Setname ehsl_novel_shw
Date Created 2008-10-27
Date Modified 2017-02-23
ID 188656
Reference URL
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