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1 Bilateral INOs and partial 3rd nerve palsiesThis is a 45-year-old man with progressive ptosis and ophthalmoparesis. 10 years prior to presentation, he experienced diplopia and had a hyperintense lesion involving the medial longitudinal fasciculus (MLF) per report. Over time, he developed bilateral adduction paresis, ptosis and upgaze paresis ...Abnormal Range, Third Subnuclear, INO, Mesencephalon
2 Brainstem ocular motor machinerySeen here is a sagittal view of the brainstem. The medulla has a significant role in gaze-holding, and the nucleus prepositus hypoglossi (NPH, along with the medial vestibular nucleus ) is the horizontal neural integrator. The abducens (6th) nucleus is located in the dorsal pons, and sends off the 6...Medulla OMS, Pons OMS, Mesencephalon OMS, Dorsal Midbrain OMS
3 Central (Nuclear) 3rd Nerve PalsiesShown here are two patients with left sided midbrain pathology (hemorrhage and ischemia) which caused damage to the 3rd nucleus. Both of the patients have ipsilateral mydriasis, adduction, supra- and infraduction paresis. Ipsilateral>contralateral ptosis is also present, and localizes to the central...Range of eye movements/motility abnormal; Third nuclear; Upgaze palsy; Downgaze palsy; Mesencephalon; Jerk nystagmus; Rotary nystagmus
4 Central 4th nerve palsy with contralateral Horner's syndromeThis is a 60-yo-woman who presented with a complaint of diplopia. Examination demonstrated a left hypertropia that worsened in right and down gaze as well as in left head tilt, and a left 4th nerve palsy was diagnosed. There was also evidence of a mild motility deficit in down/medial gaze OS, consis...Horner's, Fourth nerve palsy, Mesencephalon
5 Central anatomy of the IIIrd nerveSeen here is an axial section of the midbrain at the level of the superior colliculus. The paired nuclei are located ventral to the periaqueductal grey, and the midline central caudal nucleus (CCN) is located between the right and left nuclei. The CCN sends projections to bilateral levator palpebrae...Mesencephalon, Figures, Third Nerve Palsy
6 Central anatomy of the IVth nerveThe IVth or trochlear nucleus is located ventral to the central periaqueductal grey matter, dorsal to the medial longitudinal fasciculus (MLF) and medial to the oculosympathetic tract at the level of the inferior colliculus. The fascicles of the IVth nerve travel dorsally and caudally around the cen...Figures; Mesencephalon OMS
7 Coronal section of the brainstem showing ocular motor nuclei and anatomy of the vestibular nucleus (with SCC inputs)(A) Seen here is a coronal view of the brainstem showing the locations of the ocular motor nuclei (IIIrd, IVth, VIth) as well as the nuclei of VII and VIII (vestibular and cochlear). The vestibular nucleus (VN) is divided into the inferior, lateral, medial, and superior subnuclei, and the medial ves...Pons, Medullar OMS, Mesencephalon OMS, figures
8 Eyelid retraction, pseudoabducens and upgaze palsy due to a mesodiencephalic hemorrhageThis 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 dis...OMS Mesenecephalon, Convergence Reaction Nystagmus, Upgaze Palsy, Abnormal Range, Sixth Nerve Palsy, Vertical Gaze Palsy, Eyelid Retraction, OMS Dorsal Midbrain
9 Mesodiencephalic stroke causing unilateral riMLF and INC ocular motor syndromesThis is a 65-year-old man who experienced the sudden onset of diplopia (with horizontal and vertical components), dysarthria and imbalance. An MRI performed the following day showed a left mesodiencephalic stroke. The patient was seen in clinic 10 days later (when the video was taken), and by that t...Abnormal Saccades, Abnormal Alignment, Mesencephalon, Jerk Nystagmus, Torsional Nystagmus
10 Ocular motor signs in early progressive supranuclear palsyThis is a 64-year old man who experienced imbalance and falls (usually backwards) for the last 6 months. He experienced difficulty navigating stairs and had become a messy eater (thought to be in large part due to his vertical gaze palsy), and had developed hypophonia. Exam demonstrated square wave ...Abnormal Saccades, Abnormal Convergence, Abnormal Pursuit, Abnormal Range, Abnormal VORS, Vertical Gaze Palsy, Downgaze Palsy, OMS Mesencephalon
11 Ocular motor signs in progressive supranuclear palsy (PSP)This is a 65-yo-woman complaining of imbalance and double vision. She had significant convergence insufficiency (and would close her right eye with near viewing), providing an explanation for her diplopia. Convergence insufficiency is very common with parkinsonism. She had bradykinesia and rigidity,...Abnormal Pursuit, Abnormal Range, Upgaze Palsy, Downgaze Palsy, Mesencephalon, Square Wave Jerks
12 Sagittal section of the brainstem showing structures related to normal eyelid functionSeen here is a sagittal view of the brainstem, with the structures relevant to normal eyelid function highlighted. The M-group, which can be found medial to the riMLF (coordinates eye and lid movements), has (weak) projections to the facial nucleus for frontalis muscle contraction, and (strong) proj...Figures; Mesencephalon OMS
13 Sagittal section of the midbrain showing structures related to normal eyelid functionDuring a vertical saccade, the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) is activated, which excites the superior rectus (SR) and inferior oblique (IO) (IIIrd nerve) subnuclei. Additionally, the riMLF activates the nearby M-group. The M-group's primary excitatory out...Figures; Mesencephalon OMS
14 Test Your Knowledge - Vertical saccadic palsy due to bilateral riMLF infarctionsThis is a 30-year-old who was found minimally responsive on the lounge floor of an ice skating rink. He was brought to the ED, where he had a GCS score of 8 (where 15 is normal) for poor responsiveness. His ocular motor exam is shown in the video.; ; Regarding Finding #1, which of the following is f...Abnormal Saccades, Normal Optokinetic, Abnormal Range, Vertical Gaze Palsy, Upgaze Palsy, Downgaze Palsy, Mesencephalon, Ocular Motor
15 Test your knowledge - Parinaud's syndrome in neurosarcoidosisWatch the first segment of the video up to "Stop! What would you expect with vertical gaze?" and select the best response below. The patient also has mild right-beating nystagmus which can be ignored for the purposes of this question. ; A.; The patient has pupillary findings consistent with bilatera...Normal Convergence, Vertical Gaze Palsy, Upgaze Palsy, Dorsal Midbrain, Mesencephalon, Convergence Retraction
16 Vertical gaze palsy and saccadic intrusions due to anti-Ri from head and neck carcinomaA 55-yo- woman was admitted for imbalance and double vision. Three weeks prior to presentation she first noticed swelling on the right side of her face and neck. CT of the head and neck showed right-sided cervical adenopathy and enlarged left retropharyngeal node. Ultrasound- guided biopsy of the n...OMS Mesencephalon, Square Wave Jerks, Upgaze Palsy, Downgaze Palsy, Abnormal Range, Skew, Vertical Gaze Palsy
17 Vertical-Torsional Pendular Nystagmus and Convergence Spasm Due to Anti-MaTa EncephalitisThis is a 50-yo-woman with debilitating oscillopsia due to a high frequency (6 Hz) vertical-torsional pendular (quantitative eye movement recordings were performed) nystagmus. She also had intermittent double vision due to (organic) convergence spasm. Her nystagmus and spasm were thought to be relat...Mesencephalon; Pendular nystagmus; Convergence spasm
18 riMLF Syndrome from Artery of Percheron StrokeThis is a 65-yo-man who suffered the abrupt onset of loss of consciousness followed by difficulty looking down. MRI showed bilateral rostral midbrain strokes in the distribution of the artery of Percheron. He could not initiate downward saccades and had fair upward saccades. However, downward vestib...Saccades abnormal; Vestibulo-ocular reflex and head impulse testing normal; Pursuit normal; Vertical gaze palsy; Downgaze palsy; Mesencephalon
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