Loss of vertical gaze – the Parinaud syndrome

Introduction: Loss of vertical gaze in combination with oculomotoric disturbances are called Parinaud-syndrome. The variable loss of vertical gaze is caused by unilateral tegmental lesions in the mesencephalon. Upward eye movement cause convergence reactions and nystagmus. The often large pupils react slowly to light and pathological eyelid-retraction may occur. Tumours, multiple sclerosis or disrupted blood supply are mainly responsible for the Parinaud syndrome.

Case Report: A 15 year old adolescent complained of acute headache, light-headedness, double and blurred vision. Ophthalmologic examination revealed medium wide pupils, anisocoria, a slow reaction of the pupils to light, vertical squinting, impossible upward movement of the right eye and minimal upward movement of the left eye. Miosis induced a convergence reaction. Downgaze was affected the opposite way. Provoked upwards gaze caused a convergence-retraction nystagmus. Close vision was affected by spasms of accommodation. Further examination of the eye was normal. An MRI scan revealed an ischemic area in the right pedunculus cerebri and neighbouring thalamus. In the angio-MR studies the right arteria comm. post. could not be seen. The biochemical parameters showed no signs of infection, cerebral necrosis, coagulopathy or vasculitis. Electrophysiological studies, vestibularis examination and audiogram were also normal. A follow-up MRI-scan showed a 9mm large scar in the previously infarcted area. Clinically he was free of symptoms; on detailed examination a minimal anisocoria was seen.

Conclusion: The Parinaud syndrome warrants a quick interdisciplinary management in order to deliver adequate treatment. Cerebral infarction was the cause in this case. Under acetylsalicylic acid therapy and further general paediatric measures, a near disappearance of symptoms was seen.