Neurotogical study of a patient with upward gaze paralysis

Abstract

A patient with ataxia, ophthalmoplegia and areflexia, suspected to be a typical case of Fisher syndrome or Parinaud syndrome was examined at the Yamaguchi University Hospital.
This paper is presented from the neurotological standpoint of view. A 72 year old female had a tinnitus, hearing impairment and “heavy head” sensation for two years.
In the two months prior to the first visit, double vision and gait disturbance developed following a sudden rise in blood pressure (from ususal blood pressure, 140/60mmHg, to 200mmHg). Upward gaze paralysis and mild speech disturbance developed, and remained. Body posture on sitting was normal.
Righting reflex tests : poor and unstable, i.e., not able to stand upright even in the Romberg test. Writing tests (Fukuda's test and Sekitani's Square Drawing Test) revealed ataxia with tremor, and marked macrographism and deviation to the left side.
Optokinetic test (OKP) : poor elicitation with questionable inversion. Eye tracking test (ETT, horizontal and vertical) was saccadic in character. CT scan : within normal in the figure. Lumbar puncture and CSF study : within normal range.
She was treated with steroids, vitamins and a vasodilator drug for a short period. Clinical course was favorable with fair recovery of ataxia and areflexia, and also a reduction in “heavy head”, but the upward gaze paralysis remained for a year and a half. Localization of the lesion was considered to be around the pretectal area of the midbrain; bilateral, although more involvement on the right side with a lesion in the tegmentum.