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Horizontal Eye Movement Disorders After Posterior Vermis Infarctions

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Horizontal Eye Movement Disorders After Posterior Vermis Infarctions Journal ofNeurology, Neurosurgery, and Psychiatry 1995;58:91-94 91 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.1.91 on 1 January 1995. Downloaded from SHORT REPORT Horizontal eye movement disorders after posterior vermis infarctions K Vahedi, S Rivaud, P Amarenco, C Pierrot-Deseilligny Abstract of this study was to analyse quantitatively sac- The horizontal saccade, smooth pursuit, cade accuracy and smooth pursuit velocity in and vestibulo-ocular reflex gains were patients with a recent and pure cerebellar recorded in 19 patients with cerebellar infarction, documented by MRI. infarction documented with MRI, and in a group of control subjects. Bilateral sac- cade hypometria and a decrease in ipsi- Patients and methods lateral smooth pursuit gain were found Nineteen patients (mean (SD) age 56 (15) only in patients with a lesion affecting years) with a cerebellar infarction were stud- the posterior vermis. These results in ied. Patients with a coexisting brainstem humans support experimental findings infarction or any clinical sign or radiological suggesting that the posterior vermis con- evidence of oedematous brainstem compres- trols both saccade accuracy and smooth sion were not included. The location of the pursuit velocity. infarction was defined from MRI axial sec- tions and previously published templates (3 Neurol Neurosurg Psychiatry 1995;58:91-94) based on pathological studies of 64 cerebella.8 10 Coronal and sagittal sections were also cor- related with Courchesne's templates." 12 Two Keywords: cerebellum; eye movements patient groups were constituted according to presence and absence ofvermal involvement. In the monkey, two cerebellar regions, the flocculus and the posterior vermis, are known GROUP 1 to be involved in smooth pursuit. Bilateral This group comprised nine patients (mean ablation of the flocculi and portions of the (SD) age 65 (11) years) with an infarction paraflocculi results in a reduction of smooth involving the cerebellar vermis (figure). The http://jnnp.bmj.com/ pursuit velocity to 65% of normal values, vascular territory involved was that of the which decreases to 30-40% with the addi- posterior inferior cerebellar artery, on the tional ablation of the posterior vermis (lobuli right side in six cases and on the left side in IV to VIII).I Neural activity related to smooth three (one case associated with an ipsilateral pursuit has been recorded in these two struc- infarct involving the superior cerebellar artery tures.2 Furthermore, the posterior vermis and territory). In the cerebellar vermis, the infarc- underlying fastigial nuclei are involved in the tions affected variably lobuli VI to X (the on September 24, 2021 by guest. Protected copyright. control of saccade accuracy, as ablation of clivus, tuber, pyramis, uvula, and nodulus), these structures in the monkey results in sac- corresponding to the posterior vermis. Lobuli cade dysmetria.3 4 Neural activity related to VIII and IX were damaged in all cases and saccades has been recorded in vermal lobuli lobuli VI and VII in four cases. The inferior Service de Neurologie, VI and VII in the monkey.2 Anatomical data part of the ipsilateral cerebellar hemisphere H6pital Saint- suggest that the oculomotor vermis projects was also damaged, including variably the ton- Antoine, Paris, France predominantly to the ipsilateral mediocaudal sil, the lobuli biventer, gracilis, semilunaris K Vahedi fastigial nucleus.5 inferior, and the inferior part of the lobulus P Amarenco The ocular motor signs resulting from semilunaris superior. The flocculus and the Service de Neurologie lesions affecting specific cerebellar regions dentate nuclei were not affected by any of the and Unite INSERM have not yet been precisely defined in infarctions. Brain MRI did not show recog- 289, Hopital de la Salpftrikre, Paris, humans. Electro-oculographic studies of nisable fastigial nuclei. Eye movements were France patients with cerebellar lesions have often recorded on average 35 (SD 42) days after S Rivand involved degenerative, tumorous, or demyeli- onset of the stroke. C Pierrot-Deseilligny nating processes, usually not confined to the Correspondence to: Dr K Vahedi, Service de cerebellum. Electro-oculographic studies of GROUP 2 Neurologie, H6pital Saint- patients with focal and pure cerebellar lesions This group comprised 10 patients (mean Antoine, 184 rue de Faubourg Saint-Antoine, have rarely been performed.67 Because infarc- (SD) age = 47 (12) years) with a cerebellar 75012 Paris, France. tion topography has been described in recent infarction sparing the cerebellar vermis (fig- Received 3 June 1994 pathological and radiological studies, MRI ure). The vascular territory was that of the and in revised form may be used 1 September 1994. for the radioanatomical correla- right posterior inferior cerebellar artery in Accepted 9 September 1994 tion of such lesions.8 9 Therefore, the purpose three cases and that of the superior cerebellar 92 Vahedi, Rivaud, Amarenco, Pierrot-Deseilligny Drawing ofthe cerebellar J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.1.91 on 1 January 1995. Downloaded from areas involved by the infarcts as they appear in MRI on horizontal sections, independent ofthe infarct side. (Sectionsfrom the rostral to the caudal cerebellum: (1) and (2) sections through the upper _@ . pons, (3) section through the midpons, (4) section 1 2 through the upper medulla.) A = group 1, B = group 2, L = left, R = right. The posterior vermis is represented by the hatched area. 3 4 A B artery in seven cases (two on the left side and the subject to follow a light emitting diode five on the right side). The infarction area moving sinusoidally, with an eccentricity of affected variably the tonsil, the lobuli biven- ±200, peak velocity of 230/s (frequency = ter, gracilis, and the semilunaris inferior, 0-28 Hz), and 45°/s (frequency = 0O37 Hz). superior, simplex, and anterior. The dentate The smooth pursuit gain (peak eye velocity nucleus was damaged in two patients. The over peak target velocity) was determined for flocculus was spared. Eye movements were each target velocity and each horizontal direc- recorded on average 26 (SD 19) days after tion by averaging the gain existing in 10 con- onset of the stroke. secutive cycles. The vestibulo-ocular reflex (VOR) was CONTROL GROUP tested by rotating the subjects sinusoidally in This group included nine normal subjects darkness while fixating an imagined earth- (mean (SD) age = 57 (8) years). fixed target, with an amplitude of ±200 (fre- quency = 0-3 Hz, peak velocity = 35°/s). The EYE MOVEMENT RECORDINGS peak eye velocity over peak rotation velocity Eye movements were recorded by direct cur- (VOR gain) was determined for both horizon- rent electro-oculography in darkness, with the tal directions by averaging the results of 10 head immobilised. Three types of horizontal consecutive cycles. eye movements were studied in the patient and control groups. STATISTICAL METHODS For reflexive visually guided saccades, the The saccadic, smooth pursuit, and VOR subject was instructed to fixate a central point gains in each patient group were compared and then to look as quickly as possible at a with those of the control group by analysis of http://jnnp.bmj.com/ lateral target suddenly occurring 250 left or variance, and multiple comparisons were right of the central point with unpredictable made with the Newman-Keuls procedure. timing and direction. The saccadic gain (ratio The comparison between the ipsilateral and of primary saccade amplitude to target eccen- contralateral values was made by Student's t tricity) was determined for four types of sac- test. The gain for each control subject and cades: from the central position to the side of each type of eye movement was obtained by the lesion (ipsilateral centrifugal saccade) or averaging the rightward and leftward values, on September 24, 2021 by guest. Protected copyright. the opposite side (contralateral centrifugal as no significant difference was found between saccade), and from the side of the lesion the two types of values in these subjects. (ipsilateral centripetal saccade) or the oppo- site side (contralateral centripetal saccade) to the central position. The results were aver- Results aged for each type of saccade with 15 consec- Table 1 gives the mean results. In group 1 the utive saccades in each subject. saccadic gain was decreased in both centrifu- Smooth pursuit was tested by instructing gal directions compared with that of controls Eye movement results Saccade gain (mean (SD)) Smooth pursuit gain (mean (SD)) VOR gain (mean (SD)) Centrifugal Centripetal 23°/s 45°ls 35°/s Ips Cont Ips Cont Ips Cont Ips Cont Ips Cont Group 1 0-82**t 083*t 0-89 0-89 068*t 0-78 043**tt 0-67 0-83 0-92 (n = 9) (0 08) (0 08) (0.12) (0-10) (0 24) (0-19) (0 24) (0 27) (0-15) (0 27) Group 2 0-91 0 93 0 95 0-96 0-93 0-92 0-86 0-83 0 93 0 90 (n = 10) (0 04) (0 06) (0 04) (0 05) (0-04) (0 08) (0-15) (0-15) (0-19) (0-12) Controls 0 95 0 97 0-95 0-85 0-83 (n = 9) (0 03) (0 03) (0-07) (0 06) (0-11) *p < 0-01; **p < 0-001 v controls; tp < 0-01; ttp < 0 00 group 1 v 2. Ips = ipsilateral; Cont = contralateral. Horizontal eye movement disorders afterposterior vermis infarctions 93 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.1.91 on 1 January 1995. Downloaded from (p < 0001 for ipsilateral saccades and p < Therefore, in the case of midline cerebellar 0 01 for contralateral saccades) or to that of lesions, it may be that hypermetria results group 2 (p < 0 01 in both directions). The mainly from damage to the fastigial nuclei. mean undershooting (17-18%) was similar Bilateral hypometria of mainly centrifugal for both centrifugal directions.
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