The most common brainstem stroke syndrome seems to be the lateral medullary syndrome wallenberg syndrome 1. Combination of features of benedicts and nothnagels syndromes. Close to cerebral aqueduct and pineal gland hydrocephalus and pinealoma. An unusual variant of the dorsal midbrain syndrome in ms.
Parinaud syndrome is a condition that affects your eyes ability to move up and down. Dec 18, 2017 colliers lid retraction sign, light near dissociation, upgaze paresis, convergenceretraction nystagmus, sunsetting eyes. What are the signs and symptoms of dorsal midbrain. Spontaneous intracranial hypotension presenting as a reversible dorsal midbrain syndrome marco f edi, md, roberto cantello, md, neil h. Aug 06, 2010 this is dorsal midbrain syndrome or pretectal or parinauds syndrome.
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. Parinaud syndrome symptoms, treatment, causes, diagnosis. Damage to vertical gaze center rostral interstitial nucleus of medial longitudinal fasciculus, i. 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. Khwaja dm, 1debashish chowdhury dm, 3amit batra dm, 1abhijit dasgupta dm department of neurology, gb. Colliers lid retraction sign, light near dissociation, upgaze paresis, convergenceretraction nystagmus, sunsetting eyes. Such a patient may present to the ophthalmologist but the.
This patient developed an idiopathic brainstem hemorrhage that extended from the ponto. 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. Dorsal midbrain syndrome or parinaud syndrome is a supranuclear brainstem syndrome involving the vertical gaze centre. Intracranial hypotension due to shunt overdrainage. Conjugate gaze palsies merck manuals professional edition. Colliers sign, or midbrain induced neurogenic lid retraction, is a component of the dorsal midbrain syndrome parinaud syndrome see table 15. All presented with limited upward voluntary gaze and convergence nystagmus with attempted upward voluntary gaze. Patients suffering from parinaud syndrome show vertical gaze palsy and other neurological deficits triggered by lesions of nerve nuclei located in the dorsal midbrain. A case of dorsal midbrain syndrome in 2nd trimester of pregnancy. 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. Parinaud syndrome is defined as a constellation of upward gaze palsy, convergence retraction nystagmus, lightnear dissociation, and bilateral lid retraction. Parinauds syndrome dorsal midbrain syndrome with bilateral superior oblique palsy. The dorsal midbrain syndrome is also known as parinauds syndrome, sylvian aqueduct syndrome, or pretectal syndrome.
Lesions of the dorsal midbrain give rise to a characteristic and highly localizing constellation of neuroophthalmic signs. An unusual case of parinauds syndrome pubmed central pmc. This is a vascular lesion of the posterior cerebral artery. A case of dorsal midbrain syndrome in 2nd trimester of. 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. Named after the french ophthalmologist henri parinaud 18441905, it is most commonly associated with vertical gaze palsy. Unilateral midbrain infarct presenting as dorsal midbrain. Parinaud syndrome is also known as dorsal midbrain or collicular syndrome. Dorsal midbrain syndrome with bilateral superior oblique. 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. Patients report difficulty in looking up and blurring of distant vision. Dorsal midbrain syndrome definition of dorsal midbrain.
Request pdf dorsal midbrain syndrome from a ringenhancing lesion a ringenhancing lesion is an uncommon cause of a dorsal midbrain syndrome. Parinaud syndrome has been known by many different names including dorsal midbrain syndrome, sylvian aqueduct syndrome, pretectal syndrome, and koerbersaluselschnig syndrome. 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. Looking for online definition of dorsal midbrain syndrome in the medical dictionary. Relapsing dorsal midbrain syndrome following interventions f. Convergence retraction nystagmus is considered a highly localizing sign, pointing to a lesion of the dorsal midbrain. 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. 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.
Brainstem stroke syndromes radiology reference article. Parinauds syndrome an overview sciencedirect topics. Parinauds syndrome results from injury, either direct or compressive, to the dorsal midbrain. 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. We now report quantitative analysis of vertical eye movements in seven patients with the dorsal mid brain syndrome. We report clinical and oculographic findings in seven patients with the dorsal midbrain syndrome parinauds syndrome. Relapsing dorsal midbrain syndrome following interventions.
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 parinauds syndrome is characterized by a supranuclear vertical gaze paresis upward more than downward, lid retraction, convergence. 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. This case provides additional evidence that dms in this setting is caused by deformation of the dorsal midbrain. The lesion was localized to the dorsal midbrain on neuroimaging. 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. The authors present the case of a 9yearold girl with dorsal midbrain syndrome. The lid retraction worsens with attempted upgaze and is believed to be due to disinhibition of the lps muscles schmidtke and buttnerennever, 1992. Pdf spontaneous intracranial hypotension presenting as a. The syndrome of lightnear dissociation, limited upgaze parinauds syndrome, and retractory nystagmus on attempted upgaze is strong evidence for a dorsal midbrain lesion. The prognosis varied depending on tumour types, age of presentation and treatment received. Dorsal midbrain syndrome has not been reported previously as a manifestation of sih. Dorsal midbrain syndrome in two cases with two different. Cogan 1964 defined the syndrome as vertical upward gaze paralysis combined with paralysis of convergence and pupillary areflexia 3.
Structures involved in this syndrome would include the corticospinal and corticobulbar tracts. The aetiology of parinaud syndrome differs with age. These are case series with three patients who were diagnosed with 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. Its importance lies in that recognition of parinaud syndrome localizes pathology to impingement of or origin in the. In the pediatric age group, convergenceretraction nystagmus is commonly secondary to congenital aqueductal stenosis or a pinealoma. The interior contents of the midbrain can be anatomically segmented in a dorsal to ventral fashion, including the tectum, tegmentum, and basis. Patients with ms exhibit a broad diversity of ocular motor syndromes. The persistence of the gradient could lead to a global dysfunction of the upper midbrain. Arterial supply posterior cerebral artery stroke upward gaze palsy. The lesion is in the rostral dorsal midbrain, damaging the superior colliculi and pretectal structures.
Parinauds syndrome, is an inability to move the eyes up and down. Dorsal midbrain syndrome, parinaud syndrome youtube. 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 treatment mainly depends upon the underlying cause of the disease, as different etiologies can involve in dorsal midbrain syndrome. Middle midbrain involvement was the most common, mainly in the paramedian territory supplied by the basilar artery. However, parinauds syndrome has since been defined in several publications with the specific inclusion of upward gaze paralysis, ignoring hearing dysfunction 35. Figure 3 midbrain anatomy at the level of the superior colliculus. 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. 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. Dorsal midbrain syndrome from a ringenhancing lesion.
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. Read more about symptoms, diagnosis, treatment, complications, causes and prognosis. Perhaps distortion of structures in this brain region can occur in sih as it does. Dorsal midbrain syndrome with bilateral superior oblique palsy. 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.
Dorsal midbrain syndrome secondary to pineal gland tumours. Dorsal midbrain syndrome and parinaud syndrome eccles. It is caused by compression of the vertical gaze center at the rostral interstitial nucleus of medial longitudinal fasciculus rimlf. Interplay between midbrain and dorsal anterior cingulate regions arbitrates lingering reward effects on memory encoding. 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. Pdf current research has indicated an apparent pandemic of fear of the neural. Dorsal midbrain syndrome in multiple sclerosis with magnetic resonance imaging correlation. Midbrain tegmentum an overview sciencedirect topics. 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.
Lesions affecting the dorsal midbrain can result in a constellation of ocular findings such as vertical gaze disturbances, convergence retraction nystagmus, lig. Parinaud syndrome consists of supranuclear vertical gaze palsy secondary to lesions damaging the vertical gaze centre in the posterior commissure of the dorsal midbrain. In patients without a definite lesion on initial studies, repeat neuroimaging of the dorsal midbrain may be indicated. Most cases are related to a problem with a part of your. 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 describes a number of related clinical observations brought about by lesions of the dorsal midbrain. Although extremely rare, this syndrome can also be a result of an infarct to. Heshowedsignsofadorsal midbrain parinaud syndrome supranuclear upgaze palsy, convergence retraction nystagmus, collier sign. Dorsal midbrain syndrome most commonly results from superior colliculi compression due to mass effect from a pinealoma. The dorsal midbrain syndrome is characterized by loss of all types of upward eye movements, but relative sparing of the vestibuloocular reflex vor. 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 clinical signs and symptoms of the dorsal midbrain syndrome have specific localizing value, and careful directed neuroimaging studies usually will disclose an etiology. Case report a 33yearold man with newonset visual complaints was found to have upgaze paresis, eyelid retraction, and. 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. Lee lectures medical students on dorsal midbrain syndrome. The centrally located tegmentum represents the largest portion of midbrain real estate and contains cranial nerve nuclei in addition to gray matter and. Leighs disease associated with a dorsal midbrain syndrome. Sylvian aqueduct syndrome and global rostral midbrain. Most cases are related to a problem with a part of your midbrain known as the tectal plate. Quantitative analysis of vertical eye movements documented characteristic abnormalities of saccades with relative preservation of reflex eye. 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.
Ipsilateral 3rd nerve palsy with contralateral chorea,tremors, athetosis. Parinaud syndrome, also known as the dorsal midbrain syndrome, is a supranuclear vertical gaze disturbance caused by compression of the superior tectal plate. Dorsal midbrain syndrome casebased neuroophthalmology. Quantitative analysis of vertical eye movements documented characteristic abnormalities of saccades with relative preservation of reflex eye movements ie. Interplay between midbrain and dorsal anterior cingulate. 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. 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. Parinauds syndrome may also results from injury, either direct or compressive, to the dorsal midbrain.
Third nerve fibers andor third nerve nucleus on side opposite lesion hemiataxia. That is why parinaud syndrome is also called dorsal midbrain syndrome. 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. Lid retraction collier sign downward gaze preference settingsun sign convergenceretraction nystagmus. Intracranial hypotension due to shunt overdrainage presenting as reversible dorsal midbrain syndrome 1meena gupta dm, 2yogesh patidar dm, 1geeta a. The dorsal midbrain syndrome of parinaud usually results from damage to premotor pathways for binocular upward gaze in the dorsal mesencephalon.
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