Webers syndrome, also known as superior alternating hemiplegia, is a form of stroke characterized by the presence of an ipsilateral oculomotor nerve palsy and contralateral hemiparesis or hemiplegia. The persistence of the gradient could lead to a global dysfunction of the upper midbrain. What are the signs and symptoms of dorsal midbrain. Lid retraction collier sign downward gaze preference settingsun sign convergenceretraction nystagmus.
A detailed diagnosis including neuroimaging like ct scan and mri tests are essential to diagnose the actual reason of dorsal midbrain syndrome 1,2,3,4. Structures involved in this syndrome would include the corticospinal and corticobulbar tracts. The dorsal midbrain syndrome is characterised by 1 impaired voluntary vertical eye movements, 2 lightnear dissociation of the pupillary response pseudoargyll robertson pupils, 3 convergence nystagmus on attempted upward gaze, 4 lid retraction collier sign and 5 skew deviation. Lee lectures medical students on dorsal midbrain syndrome. Request pdf dorsal midbrain syndrome from a ringenhancing lesion a ringenhancing lesion is an uncommon cause of a dorsal midbrain syndrome. Damage to vertical gaze center rostral interstitial nucleus of medial longitudinal fasciculus, i. Although many different brainstem stroke syndromes have been classically described, the majority appear extremely rarely in the literature and are mainly for historical interest only 1. Parinaud syndrome has been known by many different names including dorsal midbrain syndrome, sylvian aqueduct syndrome, pretectal syndrome, and koerbersaluselschnig syndrome. Most cases are related to a problem with a part of your midbrain known as the tectal plate. The dorsal midbrain parinauds syndrome is characterized by a supranuclear vertical gaze paresis upward more than downward, lid retraction, convergenceretraction nystagmus, pupillary lightnear dissociation, and pseudoabduction deficits caused by excessive convergence tone. Parinaud syndrome symptoms, treatment, causes, diagnosis. Close to cerebral aqueduct and pineal gland hydrocephalus and pinealoma. Dorsal midbrain syndrome definition of dorsal midbrain.
Dorsal midbrain syndrome has not been reported previously as a manifestation of sih. Pdf spontaneous intracranial hypotension presenting as a. The centrally located tegmentum represents the largest portion of midbrain real estate and contains cranial nerve nuclei in addition to gray matter and. Most cases are related to a problem with a part of your. A case of dorsal midbrain syndrome in 2nd trimester of pregnancy. Specifically, compression or ischemic damage of the mesencephalic tectum, including the superior colliculus adjacent oculomotor origin of cranial nerve iii and edingerwestphal nuclei, causing dysfunction to the motor function of the eye. Leighs disease associated with a dorsal midbrain syndrome. Dec 18, 2017 colliers lid retraction sign, light near dissociation, upgaze paresis, convergenceretraction nystagmus, sunsetting eyes. Lesions of the dorsal midbrain give rise to a characteristic and highly localizing constellation of neuroophthalmic signs. Aug 06, 2010 this is dorsal midbrain syndrome or pretectal or parinauds syndrome. The dorsal midbrain parinauds syndrome is characterized by a supranuclear vertical gaze paresis upward more than downward, lid retraction, convergence. Its importance lies in that recognition of parinaud syndrome localizes pathology to impingement of or origin in the.
Dorsal midbrain syndrome most commonly results from superior colliculi compression due to mass effect from a pinealoma. The lesion is in the rostral dorsal midbrain, damaging the superior colliculi and pretectal structures. This is a vascular lesion of the posterior cerebral artery. Quantitative analysis of vertical eye movements documented characteristic abnormalities of saccades with relative preservation of reflex eye movements ie. This patient developed an idiopathic brainstem hemorrhage that extended from the ponto. May 31, 2016 parinaud syndrome ps is a collection of eye movement and pupillary response dysfunction most commonly caused by compression or lesion of the dorsal midbrain. Parinauds syndrome describes a number of related clinical observations brought about by lesions of the dorsal midbrain. An unusual case of parinauds syndrome pubmed central pmc.
We further hypothesise that ganglioside gq1b, or a similar molecule is present in the tectal region of the midbrain, and can be a target of the antibodies. Colliers sign, or midbrain induced neurogenic lid retraction, is a component of the dorsal midbrain syndrome parinaud syndrome see table 15. Such a patient may present to the ophthalmologist but the. The tectum is the most dorsal aspect of the midbrain and includes the quadrigeminal plate as well as additional gray matter and fiber tracts residing dorsal to the cerebral aqueduct. This case provides additional evidence that dms in this setting is caused by deformation of the dorsal midbrain.
In patients without a definite lesion on initial studies, repeat neuroimaging of the dorsal midbrain may be indicated. Named after the french ophthalmologist henri parinaud 18441905, it is most commonly associated with vertical gaze palsy. Parinaud syndrome consists of supranuclear vertical gaze palsy secondary to lesions damaging the vertical gaze centre in the posterior commissure of the dorsal midbrain. Dorsal midbrain syndrome in multiple sclerosis with magnetic resonance imaging correlation. Looking for online definition of dorsal midbrain syndrome in the medical dictionary. The lesion was localized to the dorsal midbrain on neuroimaging. The cause of diplopia, oscillopsia, and anomalous head posture in this patient was a combination of dorsal midbrain syndrome and bilateral superior oblique palsy. The dorsal midbrain syndrome is characterised by 1 impaired voluntary vertical eye movements, 2 lightnear dissociation of the pupillary response pseudoargyll robertson pupils, 3 convergence nystagmus on attempted upward gaze, 4 lid. Discussion will contain basic neuroanatomy of the brainstem from a clinicians perspective details of the blood supply of the brainstem various syndromes caused by stroke involving the brainstem vessels rule of four a very simple way to remember various brainst.
Dorsal midbrain syndrome casebased neuroophthalmology. We report clinical and oculographic findings in seven patients with the dorsal midbrain syndrome parinauds syndrome. All presented with limited upward voluntary gaze and convergence nystagmus with attempted upward voluntary gaze. Although extremely rare, this syndrome can also be a result of an infarct to. Interplay between midbrain and dorsal anterior cingulate regions arbitrates lingering reward effects on memory encoding. Conjugate gaze palsies merck manuals professional edition. Parinauds syndrome, is an inability to move the eyes up and down.
It is probable that in obstructive hydrocephalus, at the time of shunt malfunction, the development of a transtentorial pressure gradient could initially induce a functional impairment of the upper midbrain, inducing upward gaze palsy. Dorsal midbrain parinaud syndrome with corectopia nikki lindbauer, md volker strenger, md christian urban, md a yearold boy presented with emesis, blurred vision,headache,andvertigo. Unilateral midbrain infarct presenting as dorsal midbrain. The syndrome of lightnear dissociation, limited upgaze parinauds syndrome, and retractory nystagmus on attempted upgaze is strong evidence for a dorsal midbrain lesion. The vor is responsible for maintaining fixation of the eyes during head rotation and is produced by the direct vestibular input to the oculomotor nuclei in the brainstem. Khwaja dm, 1debashish chowdhury dm, 3amit batra dm, 1abhijit dasgupta dm department of neurology, gb. The prognosis varied depending on tumour types, age of presentation and treatment received. The aetiology of parinaud syndrome differs with age. Parinaud syndrome is defined as a constellation of upward gaze palsy, convergence retraction nystagmus, lightnear dissociation, and bilateral lid retraction. Its important to work with your doctor to figure out the underlying cause.
It is caused by compression of the vertical gaze center at the rostral interstitial nucleus of medial longitudinal fasciculus rimlf. This manifestation is associated with dorsal midbrain damage primarily because the movements of the eyes are controlled by the superior colliculus of the tectum, which is found in the dorsal portion of the midbrain. Relapsing dorsal midbrain syndrome following interventions. Colliers lid retraction sign, light near dissociation, upgaze paresis, convergenceretraction nystagmus, sunsetting eyes. A case of dorsal midbrain syndrome in 2nd trimester of. The dorsal midbrain syndrome is also known as parinauds syndrome, sylvian aqueduct syndrome, or pretectal syndrome. Dorsal midbrain benedikts syndrome results from a lesion in the midbrain tegmentum caused by occlusion of paramedian branches of the basilar or posterior cerebral arteries or both. Parinauds syndrome an overview sciencedirect topics. The most common brainstem stroke syndrome seems to be the lateral medullary syndrome wallenberg syndrome 1. Dorsal midbrain syndrome with bilateral superior oblique palsy. Dorsal midbrain syndrome in two cases with two different. Lesions affecting the dorsal midbrain can result in a constellation of ocular findings such as vertical gaze disturbances, convergence retraction nystagmus, lightnear dissociation of pupils, and eyelid retraction. The clinical signs and symptoms of the dorsal midbrain syndrome have specific localizing value, and careful directed neuroimaging studies usually will disclose an etiology. Pdf current research has indicated an apparent pandemic of fear of the neural.
Perhaps distortion of structures in this brain region can occur in sih as it does. In the pediatric age group, convergenceretraction nystagmus is commonly secondary to congenital aqueductal stenosis or a pinealoma. We propose that after exclusion of structural lesions in the dorsal midbrain, miller fisher syndrome should be considered in the differential diagnosis of the causes of parinauds syndrome. Arterial supply posterior cerebral artery stroke upward gaze palsy. Spontaneous intracranial hypotension presenting as a reversible dorsal midbrain syndrome marco f edi, md, roberto cantello, md, neil h. Relapsing dorsal midbrain syndrome following interventions f.
The neurological examination of the patient who had vetriculoperitoneal shunt history for hydrocephalus revealed an upward gaze palsy. The dorsal midbrain syndrome is characterized by loss of all types of upward eye movements, but relative sparing of the vestibuloocular reflex vor. The authors present the case of a 9yearold girl with dorsal midbrain syndrome. Dorsal midbrain syndrome from a ringenhancing lesion. Intracranial hypotension due to shunt overdrainage. Dorsal midbrain syndrome or parinaud syndrome is a supranuclear brainstem syndrome involving the vertical gaze centre. Convergenceretraction nystagmus induced convergenceretraction is part of the dorsal midbrain syndrome associated with paralysis of upward gaze, defective convergence, eyelid retraction, and pupillary lightnear dissociation. Dorsal midbrain syndrome and parinaud syndrome eccles. Parinaud syndrome is a condition that affects your eyes ability to move up and down. The treatment mainly depends upon the underlying cause of the disease, as different etiologies can involve in dorsal midbrain syndrome. Mar 16, 20 lateral midbrain syndrome syndrome of small penetrating arteries arising from posterior cerebral artery on side of lesion eye down and out secondary to unopposed action of fourth and sixth cranial nerves, with dilated and unresponsive pupil. Patients suffering from parinaud syndrome show vertical gaze palsy and other neurological deficits triggered by lesions of nerve nuclei located in the dorsal midbrain.
Parinaud syndrome, also known as the dorsal midbrain syndrome, is a supranuclear vertical gaze disturbance caused by compression of the superior tectal plate. We describe a patient with relapsingremitting ms who developed an unusual variation of the dorsal midbrain syndrome, character ized by monocular convergentretraction nystagmus in the right eye, accompanied by divergentretraction nystagmus in the fellow eye upon attempted upward gaze. Figure 3 midbrain anatomy at the level of the superior colliculus. Convergence retraction nystagmus is considered a highly localizing sign, pointing to a lesion of the dorsal midbrain.
Infarct in the mesencephalic territory of the posterior cerebral artery was less common, while superior cerebellar artery territory infarct was extremely rare, and posterior choroidal artery territory infarct did not occur. The dorsal midbrain syndrome of parinaud usually results from damage to premotor pathways for binocular upward gaze in the dorsal mesencephalon. The interior contents of the midbrain can be anatomically segmented in a dorsal to ventral fashion, including the tectum, tegmentum, and basis. However, parinauds syndrome has since been defined in several publications with the specific inclusion of upward gaze paralysis, ignoring hearing dysfunction 35. An unusual variant of the dorsal midbrain syndrome in ms.
These are case series with three patients who were diagnosed with dorsal midbrain syndrome secondary to pineal gland tumours. Parinaud syndrome medigoo health tests and free medical. Combination of features of benedicts and nothnagels syndromes. Parinaud syndrome definition of parinaud syndrome by. Oct 24, 2016 the presence of the full syndrome suggests either a lesion of the dorsal midbrain including the posterior commissure, bilateral lesions of the pretectal region or a large unilateral tegmental lesion daroff et al. Middle midbrain involvement was the most common, mainly in the paramedian territory supplied by the basilar artery. Lesions affecting the dorsal midbrain can result in a constellation of ocular findings such as vertical gaze disturbances, convergence retraction nystagmus, lig.
Case report a 33yearold man with newonset visual complaints was found to have upgaze paresis, eyelid retraction, and. Parinaud syndrome is also known as dorsal midbrain or collicular syndrome. That is why parinaud syndrome is also called dorsal midbrain syndrome. Parinaud syndrome is characterized by a classic triad of findings. Leighs disease is a rare progressive neurodegenerative condition caused by a mitochondrial cytopathy. This syndrome is due to a lesion in the midbrain tegmentum resulting from occlusion of paramedian branches of the basilar artery, the pca, or both. Parinauds syndrome dorsal midbrain syndrome with bilateral superior oblique palsy. Over 80% of patients with pineal tumors at presentation have features of raised intracranial pressure due to blockage of the sylvian aqueduct packer et al 1984. Dorsal midbrain syndrome secondary to pineal gland tumours. Parinaud syndrome dorsal midbrain syndrome, a conjugate upward vertical gaze palsy, may result from a pineal tumor or, less commonly, a tumor or infarct of the midbrain pretectum. Interplay between midbrain and dorsal anterior cingulate. Midbrain tegmentum an overview sciencedirect topics. Ipsilateral 3rd nerve palsy with contralateral chorea,tremors, athetosis. The lid retraction worsens with attempted upgaze and is believed to be due to disinhibition of the lps muscles schmidtke and buttnerennever, 1992.
Cogan 1964 defined the syndrome as vertical upward gaze paralysis combined with paralysis of convergence and pupillary areflexia 3. Heshowedsignsofadorsal midbrain parinaud syndrome supranuclear upgaze palsy, convergence retraction nystagmus, collier sign. Dorsal midbrain syndrome, parinaud syndrome youtube. Sylvian aqueduct syndrome and global rostral midbrain. Plus minus lid syndrome, or plus minus syndrome, is an acquired neurologic defect which includes a constellation of eye findings of unilateral ptosis and contralateral eyelid retraction. We now report quantitative analysis of vertical eye movements in seven patients with the dorsal mid brain syndrome. Brainstem stroke syndromes radiology reference article. This is an unusual case of dorsal midbrain syndrome because, first, it usually results from extrinsic compressive lesions such as thalamic and pineal gland tumours or untreated hydrocephalus, resulting in dilation of the aqueduct sylvia. Quantitative analysis of vertical eye movements documented characteristic abnormalities of saccades with relative preservation of reflex eye. Third nerve fibers andor third nerve nucleus on side opposite lesion hemiataxia.
Parinauds syndrome results from injury, either direct or compressive, to the dorsal midbrain. Patients with ms exhibit a broad diversity of ocular motor syndromes. Read more about symptoms, diagnosis, treatment, complications, causes and prognosis. Mri of the brain since this patient is suspected of having dorsal midbrain syndrome, the next most important test is an mri of the brain to look for a lesion compressing the dorsal midbrain such as pineal tumor or hydrocelphalus. Parinauds syndrome may also results from injury, either direct or compressive, to the dorsal midbrain.