- Department of Neurosurgery, University of Tsukuba,
- Department of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Japan.
Eiichi Ishikawa, Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan.
DOI:10.25259/SNI_112_2023Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Atsushi Tsukada1, Kiyoyuki Yanaka2, Eiichi Ishikawa1. Midbrain hemorrhage presenting with isolated downward gaze palsy: A case report. 07-Apr-2023;14:132
How to cite this URL: Atsushi Tsukada1, Kiyoyuki Yanaka2, Eiichi Ishikawa1. Midbrain hemorrhage presenting with isolated downward gaze palsy: A case report. 07-Apr-2023;14:132. Available from: https://surgicalneurologyint.com/surgicalint-articles/12237/
Background: Diseases presenting with only downward gaze palsy are extremely rare particular in cerebral hemorrhage.
Case Description: A 63-year-old man with no medical history developed a downward-dominant vertical gaze paralysis with a convergence disorder. Computed tomography and magnetic resonance imaging showed a small hemorrhage of 13 mm in diameter in the right midbrain tegmental area. The patient was conservatively treated. His symptoms showed a gradual improvement from upward gaze paralysis and convergence disorder followed by downward gaze paralysis. All symptoms disappeared in 3 weeks after the onset. The center of vertical eye movement was thought to be the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF) and posterior commissure (PC).
Conclusion: In this case, bilateral riMLF and PC were impaired, resulting in bilateral vertical ocular motility disorder with upward gaze paralysis. Brainstem hemorrhage rarely presents with vertical gaze palsy. Most are cerebral infarctions, and few are due to cerebral hemorrhage. This case was important for better understanding the pathophysiology of an ocular motility disorder. We also summarized the characteristics of isolated vertical gaze palsy caused by cerebral hemorrhage.
Keywords: Downward gaze palsy, Midbrain hemorrhage, Posterior commissure, Rostral interstitial nucleus of medial longitudinal fasciculus (riMLF)
Diseases presenting with vertical gaze palsy are rare and occur with vascular disorders or tumors in the dorsal midbrain.[
A 63-year-old man referred to our hospital with a sudden onset of generalized headache and diplopia that worsened in all directions, especially looking downward. On admission, there were no abnormalities in vital signs and blood tests. Neurological findings showed clear consciousness. Vertical gaze palsy, convergence disorder, bilateral light reflex loss, and diplopia, which worsened with downward gaze, were observed. Horizontal eye movements were maintained [
Time course of magnetic resonance imaging ([a and b] on admission [c and d] after 11 days). (a and c) are slice of the level of pineal gland, and (b and c) are slice of the upper level of pineal gland. The hematoma remained in the right cover and the edematous change of the posterior commissure disappeared (arrow).
This is an extremely rare case of vertical gaze palsy presenting with isolated downward gaze palsy due to cerebral hemorrhage. We considered the mechanism.
The center of vertical eye movement is said to be associated with the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF), the Cajal nucleus, the PC, and the Darkschewitsch nucleus.[
To satisfy these conditions, the lesion must be extremely localized toward the midline, so it is extremely rare for downward gaze paralysis to appear alone. In this case, the main locus of hemorrhage was in the right midbrain tegmentum, right riMLF, and edematous changes extended to the PC and contralateral riMLF. In the downward direction, it was thought that the edematous change partially extended to the vicinity of the dorsolateral oculomotor nucleus, which is considered to be the center of convergence. It is presumed that the upper gaze palsy was associated with the PC, and the lower gaze palsy was associated with dysfunction associated with bilateral riMLF and dorsolateral oculomotor nuclei due to hemorrhage and edematous changes [
Most of the cerebrovascular diseases that cause vertical gaze palsy are caused by cerebral infarction, and cerebral hemorrhage has so far occurred in only six cases, including this case [
We report a case of cerebral hemorrhage in the midbrain tegmentum presenting with isolated downward gaze paralysis. Anatomically, the bilateral riMLF and the PC were presumed to have been disturbed to the right, and this case contributed to the understanding of oculomotor disorders. We also investigated the characteristics of vertical eye movement disorders caused by cerebral hemorrhage.
Patient’s consent not required as patient’s identity is not disclosed or compromised.
There are no conflicts of interest.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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