Magnetic Resonance Imaging Correlates Of InterNuclear Ophthalmoplegia
Awerbuch G, Brown M, Levin JR
Int J NeuroSci 1990 May;52(1-2):39-43
Wayne State University School of Medicine, Department of Neurology, Detroit, Michigan 48201
InterNuclear Ophthalmoplegia (INO) is a Gaze Disorder characteristic of lesions involving the Medial Longitudinal Fasciculus (MLF).
Two patients aged 62 and 74 years presented with acute Neurologic deficits characteristic of INO. Computed axial Tomography (CT) did not detect abnormalities in the region of the MLF.
Magnetic Resonance Imaging (MRI) however, demonstrated BrainStem hypersignals with long T2 characteristics in the region of the MLF which correlated with the clinical symptoms.
These cases illustrate the value of the MRI in evaluation of patients with INO and suggest that MRI is superior to CT in evaluating Gaze Disorders attributable to Brain Dysfunction.
Abnormalities Of Horizontal Gaze. Clinical, Oculographic And Magnetic Resonance Imaging Findings. II. Gaze Palsy And InterNuclear Ophthalmoplegia
Bronstein AM, Rudge P, Gresty MA, Du Boulay G, Morris J
J Neurol NeuroSurg Psychiatry 1990 Mar;53(3):200-7
Institute of Neurology, Medical Research Council Neuro-Otology Unit, National Hospital, London, United Kingdom
The site of lesions responsible for Horizontal Gaze Palsy and various types of InterNuclear Ophthalmoplegia (INO) was established by identifying the common areas where the abnormal MRI signals from patients with a given Ocular-Motor Disorder overlapped.
Patients with UniLateral Gaze Palsy had lesions in the ParaMedian area of the Pons, including the Abducens Nucleus, the Lateral part of the Nucleus Reticularis Pontis Caudalis and the Nucleus Reticularis Pontis Oralis.
Patients with Abducens Nucleus lesions showed additional clinical signs of Lateral Rectus weakness. Lesions responsible for BiLateral Gaze Palsy involved the Pontine Tegmental Raphe.
Since this region contains the Saccadic Omnipause Neurons, this finding suggests that damage to Omnipause Cells produces slowing of Saccades rather than OpsoClonus, as previously proposed.
All INOs, regardless of the presence of impaired Abduction or Convergence, had similar MRI appearances.
Frequently the lesions in patients with INO, were not confined to the Medial Longitudinal Fasciculus (MLF) but also involved neighboring structures at the Pontine and MidBrain levels.
There was a statistically significant association between the clinical severity of the INO and the presence of abnormal Abduction or Convergence.
The findings suggest that the lesions outside the MLF, which may affect Abducens, Gaze or Convergence Pathways, are responsible for the presence of features additional to INO, depending on the magnitude of functional disruption they produce.
Identification Of InterNuclear Ophthalmoplegia Signs In Multiple Sclerosis Patients: Saccade Test Analysis
Jozefowicz-Korczynska M, Lukomski M, Pajor A
J Neurol 2008 May 2
Medical University of Lodz, Dept. of Otolaryngology, 22, Kopcinskiego str., 90-153, Lodz, Poland
Background And Purpose
Patients with Multiple Sclerosis (MS), due to the diverse nature of the disease, have many types of eye movement disorders, particularly InterNuclear Ophthalmoplegia (INO).
The aim of the study was to evaluate the usefulness of a quantitative statistical saccade test analysis for identification of INO in MS patients.
Sixty MS patients and 50 volunteers underwent clinical bedside ocularmotor examination and Electrooculographic Evaluation in a tertiary referral university hospital.
Simultaneous Electro-Oculography recordings of each eye separately were made.
In the Saccade test, the versional dysconjugacy index (VDI) for saccades velocity and the Z score analysis were applied.
Clinical eye movements disorders were found in 32 % of patients. In the MS patients saccades velocity was significantly lower compared with the control group.
Based on the results of the control group, we established the cut off values for VDI (1.04) and corresponded Z score (4.46) as the criterion indicated the presence of INO signs in MS patients.
We confirmed clinical evidence of different degrees of INO in 15 % of patients, and found subclinical INO signs in 20 % of patients.
The EOG registration is a sensitive ElectroPhysiological method for detecting subtle deficits of Ocular motility.
Saccade test analysis with calculation of the VDI and the Z-test score is a valuable method for identifying subclinical INO signs in MS patients.
Modeling Uhthoff's Phenomenon In MS Patients With InterNuclear Ophthalmoparesis
Davis SL, Frohman TC, Crandall CG, Brown MJ, Mills DA, Kramer PD, Stüve O, Frohman EM
Neurology 2008 Mar 25;70(13 Pt 2):1098-106
University of Texas Southwestern Medical Center at Dallas, Department of Neurology, 5323 Harry Hines Boulevard, Dallas, TX 75390 Elliot
The goal of this investigation was to demonstrate that InterNuclear Ophthalmoparesis (INO) can be utilized to model the effects of body temperature-induced changes on the fidelity of Axonal Conduction in Multiple Sclerosis (Uhthoff's phenomenon).
Ocular motor function was measured using infrared Oculography at 10-minute intervals in patients with Multiple Sclerosis (MS) with INO (MS-INO; n = 8), patients with MS without INO (MS-CON; n = 8), and matched healthy controls (CON; n = 8) at normothermic baseline.
During, whole-body heating (increase in core temperature 0.8 degrees C as measured by an ingestible temperature probe and transabdominal telemetry), and after whole-body cooling.
The Versional Disconjugacy Index (velocity-VDI), the ratio of abducting/adducting eye movements for velocity, was calculated to assess changes in interocular disconjugacy.
The First Pass Amplitude (FPA), the position of the adducting eye when the abducting eye achieves a centrifugal fixation target, was also computed.
Velocity-VDI and FPA in MS-INO patients was elevated (p < 0.001) following whole body heating with respect to baseline measures, confirming a compromise in Axonal electrical impulse transmission properties.
Velocity-VDI and FPA in MS-INO patients was then restored to baseline values following whole-body cooling, confirming the reversible and stereotyped nature of this characteristic feature of DeMyelination.
We have developed a NeuroPhysiologic model for objectively understanding temperature-related reversible changes in Axonal Conduction in Multiple Sclerosis.
Our observations corroborate the hypothesis that changes in core body temperature (heating and cooling) are associated with stereotypic decay and restoration in Axonal Conduction mechanisms.
Ocular Contrapulsion In Multiple Sclerosis: Clinical Features And PathoPhysiological Mechanisms
Frohman EM, Frohman TC, Fleckenstein J, Racke MK, Hawker K, Kramer PD
J Neurol NeuroSurg Psychiatry 2001 May;70(5):688-92
University of Texas Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Boulevard, Dallas, Texas 75235, USA
The objective was to describe in Multiple Sclerosis, a Cerebellar Eye Movement Syndrome that resulted from an acute episode of Inflammatory DeMyelination.
Contrapulsion is an Ocular Motor Disturbance characterised by a triad of:
- Hypermetric Saccadic eye movements in a direction opposite from a precisely localized lesion within a specific White Matter Pathway, the Uncinate Fasciculus:
- Hypometric Saccades towards the side of the lesion
- Oblique Saccades directed away from the side of the lesion on attempted Vertical Saccades
Infrared OculoGraphy was used to demonstrate the characteristic features of Contrapulsion in two patients with Multiple Sclerosis. Brain MRI showed lesions within the region of the Uncinate Fasciculus and Superior Cerebellar Peduncle in both patients.
Eye movement recordings showed Saccadic Hypermetria away from the side of the lesion and Saccadic Hypometria towards the side of the lesion.
The Hypometria decomposed into a series of stepwise movements as the Eye approached the target. Oblique Saccades directed away from the side of the lesion were seen on attempted Vertical Saccades.
In conclusion, Ocular Contrapulsion can be seen in patients with Multiple Sclerosis and results from a lesion in the region of the SCP, involving the Uncinate Fasciculus.
Complete BiLateral Horizontal Gaze Paralysis Disclosing Multiple Sclerosis
Milea D, Napolitano M, Dechy H, Le Hoang P, Delattre JY, Pierrot-Deseilligny C
J Neurol NeuroSurg Psychiatry 2001 Feb;70(2):252-5
Hopital de la Pitie-Salpetriere, Department of Ophthalmology, Paris, France
Two women presented with BiLateral InterNuclear Ophthalmoplegia evolving in a few days to complete BiLateral Horizontal Gaze Paralysis. Convergence and Vertical Eye Movements were normal.
Cerebral MRI showed a few Small White matter lesions in the Lateral Ventricle regions, and, at the BrainStem level, a single, small, BiLateral lesion affecting the posterior part of the Medial Pontine Tegmentum and responsible for the clinical syndrome.
The condition gradually improved in both patients, following a similar progression as at the onset.
Improvement first involved the Adduction movements in both eyes, whereas BiLateral Abduction Paresis still persisted for a few weeks, before complete recovery of eye movements.
BiLateral damage to the Medial Longitudinal Fasciculus and subsequent lateral extent of damage to the region of the two Abducens emerging Fibers may explain the clinical findings. In both cases, the cause was probably Multiple Sclerosis.
Dissociated Nystagmus In Side Gaze. Major Symptoms In The Diagnosis Of An InterNuclear Ophthalmoplegia
Neugebauer P, Neugebauer A, Fricke J, Michel O
HNO 2004 Jul;52(7):623-6
Klinik und Poliklinik fur Hals-Nasen-Ohren-Heilkunde des Klinikums der Universitat zu Koln
A prerequisite for a qualified analysis of Nystagmus is the recognition of uncommon forms of this condition. In InterNuclear Ophthalmoplegia (INO), a Dissociated Nystagmus in Side Gaze is typical.
This is accompanied by limited medial excursion of the Adducted Eye together with a Dissociated Nystagmus, which is stronger in the Abducting Fellow Eye.
This motility disturbance stems from a lesion in the Medial Longitudinal Fasciculus running in the BrainStem between the Sixth and the Third Nerve Nuclei.
The lesion is often due to Multiple Sclerosis, but can also be Ischemic, Traumatic, Neoplastic or Inflammatory (e.g. HIV infection).