Midsagittal pontomedullary brain stem section: effects on ocular adduction and nystagmus

Wall-Eyed Internuclear Ophthalmoplegia: History and Hypothesis

BACKGROUND

Most patients with internuclear ophthalmoplegia (INO) are orthotropic, although a subset is exotropic. When INO is bilateral, this is termed wall-eyed bilateral internuclear ophthalmoplegia (WEBINO). In 1979, Sharpe described his "first case" of wall-eyed monocular internuclear ophthalmoplegia (WEMINO) as "a unique clinical syndrome" characterized by unilateral INO and ipsilateral exotropia.

METHODS

WEMINO was clinically identified in seven patients, with oculographic correlation in six and neuropathological confirmation in one. Oculographic features of exotropic INO patients were compared with those of six orthotropic INO patients using magnetic search coil and infrared oculography.

RESULTS

All clinically defined WEMINO patients showed slowed, hypometric ipsilateral saccades by oculography. Six patients had ipsilateral exotropia, and three had ipsilateral hypertropia. Ipsilateral abducting saccades had faster peak velocities for smaller saccades, more so for orthotropic patients. Exotropic patients had normal sinusoidal mean vestibulo-ocular reflex (VOR) gains and phases; orthotropic patients had subnormal mean VOR gains and phase leads.

CONCLUSION

WEMINO is a clinical ocular motor syndrome characterized by unilateral slow, hypometric adducting saccades with exotropia and hypertropia of the ipsilateral eye. We propose that it results from discrete unilateral damage to burst-tonic fibers in the medial longitudinal fasciculus (MLF) with sparing of the adjacent extrafascicular pathways. Paradoxically, orthotropic INO results from more extensive damage to ascending pathways lateral, ventral and caudal to the MLF. Direct injury to the medial rectus subnucleus is not required. This manuscript was in preparation at the time of Dr Sharpe's death in 2013 and is an acknowledgement of his forward-thinking, as his hypotheses have stood the test of time.

Downbeat nystagmus: a clinical and pathophysiological review

Downbeat nystagmus (DBN) is a neuro-otological finding frequently encountered by clinicians dealing with patients with vertigo. Since DBN is a finding that should be understood because of central vestibular dysfunction, it is necessary to know how to frame it promptly to suggest the correct diagnostic-therapeutic pathway to the patient. As knowledge of its pathophysiology has progressed, the importance of this clinical sign has been increasingly understood. At the same time, clinical diagnostic knowledge has increased, and it has been recognized that this sign may occur sporadically or in association with others within defined clinical syndromes. Thus, in many cases, different therapeutic solutions have become possible. In our work, we have attempted to systematize current knowledge about the origin of this finding, the clinical presentation and current treatment options, to provide an overview that can be used at different levels, from the general practitioner to the specialist neurologist or neurotologist.

Vestibular Disorders after Kidney Transplantation: Focus on the Pathophysiological Mechanisms Underlying the Vertical Nystagmus Associated with Tacrolimus-Related Hypomagnesamia

The purpose of this paper is to present the case of a patient undergoing kidney transplantation who developed limb tremor dizziness and vertical nystagmus (ny) during Tacrolimus (TAC) therapy and to investigate the pathophysiological mechanisms underlying the balance disorder. This case study regards a 51-year old kidney transplant male patient with hand tremors and lower limbs asthenia associated with dizziness and nausea. The symptoms started two months after the beginning of intravenous TAC for renal transplantation. The pure-tone audiometry showed a mild symmetrical high-frequencies down-sloping sensorineural hearing loss. Acoustic emittance measures showed a normal tympanogram; stapedial reflexes were normally elicited. The Auditory Brainstem Responses (ABR) and Cervical Vestibular Evoked Myogenic Potentials (c-VEMPs) were bilaterally normally evoked. The bedside vestibular examination showed spontaneous down-beating stationary persistent, omni-positional nystagmus, not inhibited by fixation. The Head-Shaking Test accentuates the spontaneous ny. The horizontal clinical head impulse test was negative, bilaterally. A biochemical blood test revealed a decrease in Magnesium (Mg) levels (0.8 mg/dL; normal range 1.58–2.55). The integration of Mg induced both a plasma levels normalization and an improvement of clinical symptoms. This case suggests that TAC treatment can induce a Mg depletion that caused the transient cerebellar lesion. Therefore, the monitoring of serum electrolytes during immunosuppressive treatment appears to be a useful tool in order to reduce the central system symptomatology.

Downbeat nystagmus caused by a paramedian ponto-medullary lesion

Downbeat nystagmus (DBN) is rarely caused by lesions in sites other than the cerebellar (para-)floccular lobe. We describe a case of DBN secondary to a hemorrhaged venous cavernoma at the pontomedullary junction. This case provides new insights into the neuro-anatomical substrate of DBN. We propose that DBN arises from lesions in a brainstem-cerebellar feedback loop, which comprises cells of the pontine paramedian tract (PMT).

Central vestibular disorders

Dizziness or vertigo is an erroneous perception of selfmotion or object-motion as well as an unpleasant distortion of static gravitational orientation. It is caused by a mismatch between the vestibular, visual, and somatosensory systems. Thanks to their functional overlap, the three systems are able to compensate, in part, for each other's deficiencies. Thus, vertigo is not a well-defined disease entity, but rather a multisensory syndrome that results when there is a pathological dysfunction of any of the stabilizing sensory systems (e.g., central vestibular disorders, peripheral vestibular diseases with asymmetric input into the vestibular nuclei). This article provides an overview of the most important and frequent forms of central vestibular vertigo syndromes, including basilar/vestibular migraine, which are characterized by ocular motor, postural, and perceptual signs. In a simple clinical classification they can be separated according to the three major planes of action of the vestibulo-ocular reflex: yaw, roll, and pitch. A tonic imbalance in yaw is characterized by horizontal nystagmus, lateropulsion of the eyes, past-pointing, rotational and lateral body falls, and lateral deviation of the perceived straight-ahead. A tonic imbalance in roll is defined by torsional nystagmus, skew deviation, ocular torsion, tilts of head, body, and the perceived vertical. Finally, a tonic imbalance in pitch can be characterized by some forms of upbeat or downbeat nystagmus, fore-aft tilts and falls, and vertical deviation of the perceived straight ahead. The thus defined syndromes allow for a precise topographic diagnosis as regards their level and side.

Vertical nystagmus: clinical facts and hypotheses

The pathophysiology of spontaneous upbeat (UBN) and downbeat (DBN) nystagmus is reviewed in the light of several instructive clinical findings and experimental data. UBN due to pontine lesions could result from damage to the ventral tegmental tract (VTT), originating in the superior vestibular nucleus (SVN), coursing through the ventral pons and transmitting excitatory upward vestibular signals to the third nerve nucleus. A VTT lesion probably leads to relative hypoactivity of the drive to the motoneurons of the elevator muscles with, consequently, an imbalance between the downward and upward systems, resulting in a downward slow phase. The results observed in internuclear ophthalmoplegia suggest that the medial longitudinal fasciculus (MLF) is involved in the transmission of both upward and downward vestibular signals. Since no clinical cases of DBN due to focal brainstem damage have been reported, it may be assumed that the transmission of downward vestibular signals depends only upon the MLF, whereas that of upward vestibular signals involves both the MLF and the VTT. The main focal lesions resulting in DBN affect the cerebellar flocculus and/or paraflocculus. Apparently, this structure tonically inhibits the SVN and its excitatory efferent tract (i.e. the VTT) but not the downward vestibular system. Therefore, a floccular lesion could result in a disinhibition of the SVN-VTT pathway with, consequently, relative hyperactivity of the drive to the motoneurons of the elevator muscles, resulting in an upward slow phase. UBN also results from lesions affecting the caudal medulla. An area in this region could form part of a feedback loop involved in upward gaze-holding, originating in a collateral branch of the VTT and comprising the caudal medulla, the flocculus and the SVN, successively. Therefore, it is suggested that the main types of spontaneous vertical nystagmus due to focal central lesions result from a primary dysfunction of the SVN-VTT pathway, which becomes hypoactive after pontine or caudal medullary lesions, thereby eliciting UBN, and hyperactive after floccular lesions, thereby eliciting DBN. Lastly, since gravity influences UBN and DBN and may facilitate the downward vestibular system and restrain the upward vestibular system, it is hypothesized that the excitatory SVN-VTT pathway, along with its specific floccular inhibition, has developed to counteract the gravity pull. This anatomical hyperdevelopment is apparently associated with a physiological upward velocity bias, since the gain of all upward slow eye movements is greater than that of downward slow eye movements in normal human subjects and in monkeys.

Ultrastructure of vestibular commissural neurons related to velocity storage in the monkey

The angular vestibulo-ocular reflex maintains gaze during head movements. It is thought to be mediated by two components: direct and velocity storage pathways. The direct angular vestibulo-ocular reflex is conveyed by a three neuron chain from the labyrinth to the ocular motoneurons. The indirect pathway involves a more complex neural network that utilizes a portion of the vestibular commissure. The purpose of the present study was to identify the ultrastructural characteristics of commissural neurons in the medial vestibular nucleus that are related to the velocity storage component of the angular vestibulo-ocular reflex. Ultrastructural studies of degenerating medial vestibular nucleus neurons were conducted in monkeys following midline section of rostral medullary commissural fibers with subsequent behavioral testing. After this lesion, oculomotor and vestibular functions attributable to velocity storage were abolished, whereas the direct angular vestibulo-ocular reflex pathway remained intact. Since this damage was functionally discrete, degenerating neurons were interpreted as potential participants in the velocity storage network. Ultrastructural observations indicate that commissural neurons related to velocity storage are small and medium sized cells having large nuclei with deep indentations and relatively little cytoplasm, which are located in the lateral crescents of rostral medial vestibular nucleus. The morphology of degenerating dendritic profiles varied. Some contained numerous round or tubular mitochondria in a pale cytoplasmic matrix with few other organelles, while others had few mitochondria but many cisterns and vacuoles in dense granular cytoplasm. The commissural nature of these cells was further suggested by the presence of two different types of degenerating axon terminals in the rostral medial vestibular nucleus: those with a moderate density of large spherical synaptic vesicles, and those with pleomorphic, primarily ellipsoid synaptic vesicles. The recognition of two types of degenerating terminals further supports our interpretation that at least two morphological types of commissural neurons participate in the velocity storage network. The degenerating boutons formed contacts with a variety of postsynaptic partners. In particular, synapses were observed between degenerating boutons and non-degenerating dendrites, and between intact terminals and degenerating dendrites. However, degenerating pre- and postsynaptic elements were rarely observed in direct contact, suggesting that additional neurons are interposed in the indirect pathway commissural system. On the basis of these ultrastructural observations, it is concluded that vestibular commissural neurons involved in the mediation of velocity storage have distinguishing ultrastructural features and synaptology, that are different from those of direct pathway neurons.

The ultrastructure of GABA-immunoreactive vestibular commissural neurons related to velocity storage in the monkey

The purpose of the present study was to visualize the synaptic interactions of GABAergic neurons involved in the mediation of velocity storage. In the previous report, ultrastructural studies of degenerating neurons were conducted following midline section of rostral medullary commissural fibers with subsequent behavioral testing. The midline lesion caused functionally discrete damage to the velocity storage component, but not to the direct pathway, of the angular vestibulo-ocular reflex, and the degenerating neurons were interpreted as potential participants in the velocity storage network. We concluded that at least some of the commissural axons mediating velocity storage originate from clusters of neurons in the lateral crescents of the rostral medial vestibular nucleus. In the present report, immunocytochemical evidence is presented that many vestibular commissural neurons, putatively involved in mediating velocity storage, are GABAergic. These cells have large nuclei, small round or narrow tubular mitochondria, occasional cisterns and vacuoles, but few other organelles. Their axons are thinly-myelinated, and terminate in boutons containing mitochondria of similar ultrastructural appearance and a moderate density of round/pleomorphic synaptic vesicles. Such terminals often form axoaxonic synapses, and less frequently axodendritic contacts, with non-GABAergic elements. On the basis of the present results, we conclude that a portion of the commissural neurons of the velocity storage pathway is GABAergic. The observation of GABAergic axoaxonic synapses in this pathway is interpreted as a structural basis for presynaptic inhibition of medial vestibular nucleus circuits by velocity storage-related commissural neurons. Conversely, substantial ultrastructural evidence for postsynaptic inhibition of non-GABAergic commissural cells argues for a dual role for GABAergic terminals mediating velocity storage: presynaptic inhibition of non-GABAergic vestibular cells by GABAergic velocity storage commissural axons, and postsynaptic inhibition of non-GABAergic velocity storage cells by GABAergic axons. Both pre- and postsynaptic inhibitory arrangements could provide the morphologic basis for disinhibitory activation of the velocity storage network within local neuronal circuits.

Contribution of vestibular commissural pathways to spatial orientation of the angular vestibuloocular reflex

During nystagmus induced by the angular vestibuloocular reflex (aVOR), the axis of eye velocity tends to align with the direction of gravito-inertial acceleration (GIA), a process we term "spatial orientation of the aVOR." We studied spatial orientation of the aVOR in rhesus and cynomolgus monkeys before and after midline section of the rostral medulla abolished all oculomotor functions related to velocity storage, leaving the direct optokinetic and vestibular pathways intact. Optokinetic afternystagmus and the bias component of off-vertical-axis rotation were lost, and the aVOR time constant was reduced to a value commensurate with the time constants of primary semicircular canal afferents. Spatial orientation of the aVOR, induced either during optokinetic or vestibular stimulation, was also lost. Vertical and roll aVOR time constants could no longer be lengthened in side-down or supine/prone positions, and static and dynamic tilts of the GIA no longer produced cross-coupling from the yaw to pitch and yaw to roll axes. Consequently, the induced nystagmus remained entirely in head coordinates after the lesion, regardless of the direction of the resultant GIA vector. Gains of the aVOR and of optokinetic nystagmus to steps of velocity were unaffected or slightly increased. These results are consistent with a model in which the direct aVOR pathways are organized in semicircular canal coordinates and spatial orientation is restricted to the indirect (velocity storage) pathways.

Treatment of abnormal eye movements that impair vision: strategies based on current concepts of physiology and pharmacology

Certain abnormal eye movements, especially pathological nystagmus, degrade vision and cause illusory motion of the seen environment. These symptoms are due to excessive movement of images of stationary objects on the retina. Recently, the pathophysiology underlying several types of nystagmus and saccadic oscillations was better defined by the development of animal models and by experimental pharmacological studies. Despite this, few reliable therapies are currently available for these abnormal eye movements. In clinical studies, a number of drugs reportedly helped individual patients, but few drugs have been subjected to double-blind trials. An alternative approach to pharmacological suppression of abnormal eye movements is optical stabilization of images on the retina, which is helpful in selected patients. Weakening of the extraocular muscles, using botulinum toxin or surgery, is prone to cause diplopia and may induce plastic-adaptive changes that render the effect temporary. In some patients, treatment of an underlying condition, such as the Arnold-Chiari malformation, reduces nystagmus and improves vision. There is a need for multicenter trials to evaluate systematically potential treatments of abnormal eye movements that impair vision.

A case of Bickerstaff's encephalitis. With special reference to neurotological findings

The case of a 60-year old male with prodromal common cold symptoms and progression of brain stem involvement with no cardiac or respiratory complications is described. This conformed to the criteria of Bickerstaff's encephalitis. Neurotological examinations, including the OKN test, the caloric test, and the GBST were performed from onset to recovery of the disease. The results of these tests closely reflected the central nervous system disorders each time, but there was a discrepancy in the results of the two test batteries of equilibrium function, the caloric test and the GBST. The caloric test showed bilateral canal paresis while the GBST showed normal responses. These results suggested that the involved area of the vestibular nucleus was localized to the superior portions. Form our clinical observations, we can conclude that neurotological examinations provide more vital information for localized diagnosis and follow-up of the brain stem lesion in Bickerstaff's encephalitis.

The nucleus of the optic tract. Its function in gaze stabilization and control of visual-vestibular interaction

1. Electrical stimulation of the nucleus of the optic tract (NOT) induced nystagmus and after-nystagmus with ipsilateral slow phases. The velocity characteristics of the nystagmus were similar to those of the slow component of optokinetic nystagmus (OKN) and to optokinetic after-nystagmus (OKAN), both of which are produced by velocity storage in the vestibular system. When NOT was destroyed, these components disappeared. This indicates that velocity storage is activated from the visual system through NOT. 2. Velocity storage produces compensatory eye-in-head and head-on-body movements through the vestibular system. The association of NOT with velocity storage implies that NOT helps stabilize gaze in space during both passive motion and active locomotion in light with an angular component. It has been suggested that "vestibular-only" neurons in the vestibular nuclei play an important role in generation of velocity storage. Similarities between the rise and fall times of eye velocity during OKN and OKAN to firing rates of vestibular-only neurons suggest that these cells may receive their visual input through NOT. 3. One NOT was injected with muscimol, a GABAA agonist. Ipsilateral OKN and OKAN were lost, suggesting that GABA, which is an inhibitory transmitter in NOT, acts on projection pathways to the brain stem. A striking finding was that visual suppression and habituation of contralateral slow phases of vestibular nystagmus were also abolished after muscimol injection. The latter implies that NOT plays an important role in producing visual suppression of the VOR and habituating its time constant. 4. Habituation is lost after nodulus and uvula lesions and visual suppression after lesions of the flocculus and paraflocculus. We postulate that the disappearance of vestibular habituation and of visual suppression of vestibular responses after muscimol injections was due to dysfacilitation of the prominent NOT-inferior olive pathway, inactivating climbing fibers from the dorsal cap to nodulouvular and flocculoparafloccular Purkinje cells. The prompt loss of habituation when NOT was inactivated, and its return when the GABAergic inhibition dissipated, suggests that although VOR habituation can be relatively permanent, it must be maintained continuously by activity of the vestibulocerebellum.

Tonic activity of rat medial vestibular nucleus neurones in vitro and its inhibition by GABA

The spontaneous discharge of 48 medial vestibular nucleus (MVN) neurones was recorded extracellularly in horizontal slices of the rat brainstem in vitro. The mean tonic rate of discharge was 17.1 +/- 8.2 imp/s, similar to that observed by others in transverse (coronal) slices of the rat and guinea pig MVN. The tonic rate of discharge of individual MVN cells either increased or decreased after synaptic blockade in low Ca2+ media, suggesting that ongoing synaptic activity has an important influence on the spontaneous activity of MVN cells in vitro. However the persistence of tonic activity after synaptic blockade indicates that an intrinsic, pacemaker-like mechanism is involved in the generation of the tonic activity. GABA, muscimol, baclofen and 3-APA inhibited the tonic activity of all MVN cells tested. Bicuculline antagonised, and picrotoxin blocked, the inhibitory responses to muscimol, but the effects of GABA were only partially blocked in 50 microM picrotoxin. The effects of baclofen and 3-APA persisted in low Ca2+ media, and were antagonised by saclofen and phaclofen. Picrotoxin-resistant responses to GABA persisted in low Ca2+ media, and were also antagonised by saclofen. These results suggest that the inhibitory control of MVN neurones by GABA involves both the GABAA and GABAB subtypes of GABA receptor. GABAB receptors appear to be distributed both pre- and post-synaptically in the rat MVN. The possible significance of the intrinsic, tonic activity of MVN cells in normal vestibular function and in vestibular compensation, and the effects of GABA, are discussed.

Effects of midline medullary lesions on velocity storage and the vestibulo-ocular reflex

1. Crossing fibers were sectioned at the midline of the medulla caudal to the abducens nucleus in four cynomolgus monkeys. In two animals the lesions caused the time constant of horizontal and vertical per- and post-rotatory nystagmus to fall to 5-8 s. The slow rise in optokinetic nystagmus (OKN), as well as optokinetic after-nystagmus (OKAN) and cross-coupling of horizontal to vertical OKN and OKAN were abolished. Steady state velocities could not be maintained during off-vertical axis rotation (OVAR). Pitch and yaw nystagmus were affected similarly. We conclude that the ability to store activity related to slow phase eye velocity, i.e., "velocity storage", was lost in these monkeys for nystagmus about any axis. Velocity storage was partially affected by a small midline lesion in the same region in a third animal. There was no effect of a more superficial midline section in a fourth monkey, and it served as a control. 2. The gain (eye velocity/head velocity) of the vestibulo-ocular reflex (VOR) was unaffected by the midline lesions. Saccades were normal, as was the ability to hold the eyes in eccentric gaze positions. The gain of the fast component of OKN increased in one monkey to compensate for the loss of the slow component. 3. One animal was tested for its ability to adapt the gain of the VOR due to visual-vestibular mismatch after lesion. Average changes in gain in response to wearing magnifying (2.2x) and reducing (0.5x) lenses, were +35% and -30%, respectively. This is within the range of normal monkeys. Thus, a midline lesion that abolished velocity storage did not alter that animal's ability to adapt the gain of the VOR. 4. Lesions that reduced or abolished velocity storage interrupted crossing fibers in the rostral medulla, caudal to the abducens nuclei. Cells that contributed axons to this portion of the crossing fibers are most likely located in central portions of the medial vestibular nucleus (MVN) and/or in rostral portion of the descending vestibular nucleus (DVN). The implication is that velocity storage arises from neurons in MVN and DVN whose axons cross the midline.

Clinical application of saccade-reflex testing in man

Computer-aided measurements of saccade-reflex reaction times, velocities, and accuracies have become important tools in the detection of central nervous system pathology. Because of improved knowledge of the reflex pathways in man, saccade testing can assist in differentiating between brain stem, cerebellar, or cerebral disorders and point toward unilateral lesions. Saccade-reflex testing is also useful in determining disability and measuring over time the course of central nervous system disorders. Further work, correlating lesions observed by high-resolution imaging techniques with abnormalities in reflexes, continues to improve the understanding of saccade mechanisms in man. Specific cases are used to show the effects of anatomic lesions on changes in saccade reflexes. The results from 100 consecutive patients evaluated for dizziness are provided in order to illustrate the prevalence of saccade abnormalities and the relationship between abnormalities in vestibular and slow and fast eye-movement reflexes. Patients complaining of disequilibrium and visual disturbances frequently have abnormalities in the saccade system, abnormalities which are often overlooked in present clinical testing of the dizzy patient.

The effects of baclofen and cholinergic drugs on upbeat and downbeat nystagmus

The GABAergic drug baclofen and the cholinergic drug physostigmine were administered to patients with upbeat and downbeat nystagmus. Baclofen (orally, 5 mg three times daily) reduced nystagmus slow phase velocity and distressing oscillopsia by 25-75% in four out of five patients (two upbeat nystagmus; two downbeat nystagmus). Physostigmine (1 mg single intravenous injection) increased nystagmus in five additional patients with downbeat (1) or positional downbeat nystagmus (4) for a duration of 15-20 minutes. The different interactions of baclofen and physostigmine on neurotransmission subserving vertical vestibulo-ocular reflex could account for these effects. The response to baclofen appears to be a GABA-B-ergic effect with augmentation of the physiological inhibitory influence of the vestibulo-cerebellum on the vestibular nuclei. Similarly baclofen has an inhibitory effect on the velocity storage mechanism. Cholinergic action may cause the increment of nystagmus by physostigmine.

Failure of the oculomotor neural integrator from a discrete midline lesion between the abducens nuclei in the monkey

Recent anatomical studies indicate that axons of neurons in the vestibular nuclei, projecting to the contralateral abducens nuclei, cross the midline at the abducens level. These axons then give off collaterals to the contralateral vestibular and prepositus nuclei that may be important for the neural integrator that converts eye-velocity to eye-position signals. We disrupted a subset of these commissural projections by making a small midline lesion between the abducens nuclei in a monkey. The vestibulo-ocular reflex and saccades were still present post-lesion, indicating that premotor drive was intact, but the lesion produced severe post-saccadic drift, indicating failure of the neural integrator. We conclude that commissural projections crossing at the abducens level may be important for oculomotor integration.

Classification of vestibular brainstem disorders according to vestibulo-ocular reflex planes

Evidence is presented for a preliminary and speculative classification of central vestibular disorders of the brain stem according to the three major planes of action of the vestibuloocular reflex (VOR). 1. Disorders of the VOR in horizontal (yaw) plane: horizontal nystagmus-vertigo; 2. Disorders of the VOR in sagittal (pitch) plane: downbeat or upbeat nystagmus-vertigo; 3. Disorders of the VOR in frontal (roll) plane: ocular tilt reaction and lateropulsion.

Effects on the vestibulo- and opto-oculomotor system in rats by lesions of the commissural vestibular fibres

Eye movements were recorded from rats with a magnetic search coil system before and after sectioning of the midline commissural pathways in the brain stem at the level of the vestibular nuclei. After lesion, the findings were as follows: 1) During sinusoidal vestibular stimulation the eyes moved in a sinusoidal way similar to the head movement without any regular saccades. There was a reduced gain and a phase lead. 2) During optokinetic stimulation the eyes moved in the stimulus direction to an excentric position and stayed there until stimulation ceased. 3) During acceleratory/deceleratory rotation in the light there was a drift of the eyes in the direction of the expected slow phase movement to an excentric position. In some animals there was a directional asymmetry. The findings may be explained by a failure of the central neural integrator for horizontal eye movements. The results support the hypothesis that vestibular commissural fibres are of crucial importance for the function of this integrator system.

Nystagmus induced by stimulation of the nucleus of the optic tract in the monkey

1. The nucleus of the optic tract (NOT) was electrically stimulated in alert rhesus monkeys. In darkness stimulation evoked horizontal nystagmus with ipsilateral slow phases, followed by after-nystagmus in the same direction. The rising time course of the slow phase velocity was similar to the slow rise in optokinetic nystagmus (OKN) and to the charge time of optokinetic after-nystagmus (OKAN). The maximum velocity of the steady state nystagmus was approximately the same as that of OKAN, and the falling time course of the after-nystagmus paralleled OKAN. 2. Increases in frequency and duration of stimulation caused the rising and falling time constants of the nystagmus and after-nystagmus to become shorter. Changes in the falling time constant of the after-nystagmus were similar to changes in the time constant of OKAN produced by increases in the velocity or duration of optokinetic stimulation. 3. Stimulus-induced nystagmus was combined with OKN, OKAN and per- and post-rotatory nystagmus. The slow component of OKN as well as OKAN could be prolonged or blocked by stimulation, leaving the rapid component of OKN unaffected. Activity induced by electrical stimulation could also sum with activity arising in the semicircular canals to reduce or abolish post-rotatory nystagmus. 4. Positive stimulus sites for inducing nystagmus were located in the posterolateral pretectum. This included portions of NOT that lie in and around the brachium of the superior colliculus and adjacent regions of the dorsal terminal nucleus (DTN). 5. The data indicate that NOT stimulation had elicited the component of OKN which is responsible for the slow rise in slow phase velocity and for OKAN. The functional implication is that NOT, and possibly DTN, are major sources of visual information related to retinal slip in the animal's yaw plane for semicircular canal-related neurons in the vestibular nuclei. Analyzed in terms of a model of OKN and OKAN (Cohen et al. 1977; Waespe et al. 1983), the indirect pathway, which excites the velocity storage mechanism in the vestibular system to produce the slow component of OKN and OKAN, lies in NOT in the monkey, as it probably also does in cat, rat and rabbit. Pathways carrying activity for the rapid rise in slow phase velocity during OKN or for ocular pursuit appear to lie outside NOT.

Alternating skew on lateral gaze (bilateral abducting hypertropia)

We report thirty-three patients with alternating skew deviation on lateral gaze. The right eye was hypertropic in right gaze, and the left eye was hypertropic in left gaze. Most patients had associated downbeat nystagmus and ataxia and were diagnosed as having lesions of the cerebellar pathways or the cervicomedullary junction. This contrasts with a previous report in which alternating skew was seen mainly in lesions of the midbrain pretectum.

Ultralow vestibuloocular reflex time constants

We report detailed oculomotor studies in 3 patients with central nervous system lesions and markedly decreased time constants (less than 2 seconds) of the vestibuloocular reflex (VOR). In 1 patient with Chiari type I malformation, serial measurements over 3 years documented a progressive decrease in the duration of postrotatory nystagmus (100 deg/sec steps, acceleration 140 deg/sec2) until finally there was no sustained nystagmus. At this time, the patient had no response to caloric stimulation or to sinusoidal rotation below 0.2 Hz but normal gain (peak slow-phase eye velocity/peak chair velocity) above 0.4 Hz (phase lead increased). Gaze holding, saccades, smooth pursuit, and optokinetic nystagmus were normal, but optokinetic-after-nystagmus disappeared. The other 2 patients (combined brainstem-cerebellar atrophy) had impaired gaze holding, abnormal smooth pursuit and optokinetic nystagmus, and absent optokinetic-after-nystagmus. VOR gain to step and high-frequency sinusoidal stimuli was increased. The neural mechanism that normally prolongs the VOR time constant may have reduced it in our patients.

Baclofen and velocity storage: a model of the effects of the drug on the vestibulo-ocular reflex in the rhesus monkey

1. Baclofen had a characteristic effect on vestibular and optokinetic nystagmus in rhesus monkeys. Each aspect of nystagmus that is dependent on the velocity-storage mechanism in the vestibulo-ocular reflex (v.o.r.) was altered by the drug: (a) Baclofen reduced the dominant time constant of the v.o.r. in a dose-dependent manner up to 5 mg/kg, the highest dosage used. The alteration in v.o.r. time constant began within 15 min of injection, was maximal between 1 and 4 h, and lasted for 14-18 h. This effect mirrors changes in plasma levels of baclofen after oral doses in humans (Faigle, Keberle & Agen, 1980). (b) Slow-phase velocities of steady-state nystagmus induced by rotation about axes tilted from the vertical (off-vertical axis rotation, o.v.a.r.) were reduced after baclofen and could not be maintained at previous levels. (c) There was a dose-dependent decline in the steady-state gain of optokinetic nystagmus (o.k.n.), and at the highest dosages little o.k.n. was induced. In parallel, the peak velocity and falling time constant of optokinetic after-nystagmus (o.k.a.n.) were reduced. Since baclofen is a GABA agonist, systems utilizing GABA and acting on GABAB receptors appear to produce inhibitory control of velocity storage. 2. The step gain of the v.o.r., measured at the beginning and end of constant-velocity rotation in darkness, was unaffected by baclofen, as were saccades, quick phases of nystagmus, and the ability to hold positions of fixation or to generate linear slow phases of nystagmus. This indicates that it is possible to use baclofen to manipulate the dominant time constant of the v.o.r. and of o.k.a.n. in relative isolation from effects on other oculomotor components. 3. Baclofen caused a dose-dependent reduction in the initial jump in eye velocity at the onset of o.k.n., suggesting that the initial jump is also under inhibitory control of GABAB receptors. However, there were still occasional slow phases with velocities up to 30-40 deg/s after baclofen, and animals were capable of visually suppressing the v.o.r. This indicates that pathways responsible for causing rapid changes in slowphase velocity were capable of functioning, at least intermittently, in the presence of the drug.(ABSTRACT TRUNCATED AT 400 WORDS)

Down beating nystagmus: magnetic resonance imaging and neuro-otological findings

Twenty-four patients with down beating nystagmus (DBN) underwent magnetic resonance imaging (MRI) of the head. MRI provided diagnostic images in Arnold-Chiari malformation (6 cases), cerebellar atrophy (6 cases), 1 case with a prepontine-medullary epidermoid tumour and was helpful in the diagnosis of 2 patients with multiple sclerosis and 1 with a ponto-cerebellar infarct. Multiple cerebral hemisphere lesions were found in 6 patients (5 of them over 60 years of age) in whom no diagnosis was made. All cases of DBN, plus 3 additional patients with Arnold-Chiari malformation and other types of nystagmus, were neuro-otologically assessed. Sensitivity of the nystagmus to head tilt with respect to the gravity vector had no localizing value. Impaired horizontal vestibulo-ocular reflex suppression occurred more frequently in those patients with abnormal posterior fossa MRI. Pure torsional nystagmus, and DBN with a strong torsional component, in patients with Arnold-Chiari malformation was associated with syringomyelia. Magnetic resonance is the imaging method of choice for investigating patients with DBN.

Downbeat nystagmus indicates cerebellar or brain-stem lesions in vitamin B12 deficiency

Two cases of vitamin B12 deficiency caused by gastric atrophy are described. Together with the neuropsychiatric features usually associated with this condition, a downbeat nystagmus syndrome was observed. It is concluded that vitamin B12 deficiency may also result in lesions to those cerebellar or brain-stem structures that are generally assumed to cause downbeat nystagmus.

Lesions in the cat prepositus complex: effects on the optokinetic system

The effects of bilateral lesions within and around the prepositus hypoglossi (p.h.) nuclei on the optokinetic system were studied. The pure optokinetic nystagmus (o.k.n.) was evoked by a step of velocity (60 deg/s, 30 s duration) of the surrounding. The visual-vestibular interaction was investigated by measuring the gain and phase of the vestibulo-ocular reflex (v.o.r.) as a function of frequency before and after lesion under three different conditions of testing: basic v.o.r. tested in the dark, v.o.r. tested in the light and v.o.r. suppressed by vision. The tested amplitude was +/- 20 deg. A posterior vermectomy was performed for controls in two cats. A bilateral electrolytic p.h. lesion including the rostral pole of this nucleus was added to the posterior vermectomy in three cats. A lesion similar but sparing the rostral pole of the nucleus was carried out in three other cats. In one cat a bilateral electrolytic lesion of the medial vestibular nuclei (m.v.n.) was combined with a posterior vermectomy. In two cats the medulla was cut on the mid line after a posterior vermectomy. The posterior vermectomy affected neither the optokinetic response nor the visual-vestibular interactions. In cats where p.h. lesion included its rostral pole and in the cat with m.v.n. lesion, all the tested optokinetic effects (step o.k.n., and visual-vestibular interactions) were abolished. In the three cats where p.h. lesion spared its rostral pole, the optokinetic effects were quite normal in one cat, mildly reduced in the second one, and seriously affected but not completely abolished in the third one. The surgical cut of the medulla on the mid line did not dramatically disturb the various optokinetic effects. The most marked deficit was the loss of the optokinetic after-nystagmus (o.k.a.n.). From the comparison of these results with the neuroanatomical data and with the Robinson's model concerning the optokinetic processing, it was suggested that: (a) the rostral p.h. could be the location of the o.k.n. integrator or could be an essential link on the o.k.n. pathway, (b) the posterior four-fifths of the p.h. could not be an essential relay on the o.k.n. pathway, (c) the loss of o.k.a.n. after mid-line lesion could be due to the interruption of the positive feed-back loop formed by the reciprocal inhibitory connexions between the two m.v.n.

Lesions in the cat prepositus complex: effects on the vestibulo-ocular reflex and saccades

The effects of bilateral electrolytic lesions within and around the prepositus hypoglossi (p.h.) nucleus on horizontal saccades in the dark and on the horizontal sinusoidal vestibulo-ocular reflex (v.o.r.) in the dark were studied. After p.h. lesion, including its rostral part between P 7 and P 8, the v.o.r. showed a phase lead as much as about 90 deg at 0.10 Hz. A significant gain reduction paralleled that phase lead at lower frequencies. A large post-saccadic drift was also observed, the time constant of which ranged from 0.3 to 0.6 s. After p.h. lesion extending from P 8 to P 11 (but sparing the rostral part of the p.h.), no significant gain or phase lead change was observed. Post-saccadic drift was either missing or weak. A bilateral medial vestibular nucleus (m.v.n.) lesion from P 7 to P 11 produced a marked gain decrease, paralleled by a marked phase advance. A post-saccadic drift was observed (tau = 0.6 s). A surgical mid-line lesion from P 7 to P 11 (depth: about 2 mm) was followed by no remarkable change in the gain and in the phase of the v.o.r. No post-saccadic drift was observed after such lesion. It was concluded that (i) both the horizontal v.o.r. integration processing, and the horizontal saccadic integration processing were destroyed when an electrolytic lesion was made 'in the region of' the rostral part of the p.h. nucleus, and that (ii) the posterior four-fifths of the p.h. was the location of neither the horizontal v.o.r. integrator nor the horizontal saccadic integrator.

Case of downbeat nystagmus influenced by otolith stimulation

A patient with downbeat nystagmus and familial ataxia is described. The nystagmus was induced by static tilt away from normal upright posture, by linear acceleration of the head, and by convergence. It is inferred that the nystagmus was modulated by otolith-specific stimuli and not by stimulation of the canals. These findings demonstrate the role of otolith function in generation of eye movements in the vertical plane and support proposed interrelationships between otolith and vergence mechanisms. The nystagmus and associated oscillopsia were partially suppressed by treatment with clonazepam.

Functional organization of premotor neurons in the cat medial vestibular nucleus related to slow and fast phases of nystagmus

Extracellular spikes were recorded from secondary vestibular neurons in the cat medial vestibular nucleus (MVN) and were identified as type I or II neurons by horizontal rotation. Type I neurons were further classified as excitatory or inhibitory premotor neurons on the basis of their axonal termination in the contralateral or ipsilateral abducens nucleus, demonstrated by spike-triggered averaging of abducens nerve discharges, or by antidromic activation using systematic microstimulation within the abducens nucleus. Both excitatory and inhibitory premotor type I MVN neurons exhibited a rhythmic modulation of their firing rate in association with nystagmus elicited by rotation or electrical stimulation of the vestibular nerve. Their tonic activity during the slow phase was suppressed at the quick phase directed to the ipsilateral side. Excitatory type I MVN neurons terminating in the contralateral abducens nucleus sent collateral axons to the contralateral MVN. These commissural neurons also showed a nystagmus-related discharge pattern. Type II MVN neurons activated at short latency by stimulation of the contralateral vestibular nerve exhibited burst discharges when the activity of ipsilateral type I neurons was suppressed at the quick phase. These type II neurons made monosynaptic inhibitory connection with type I neurons as shown by the post-spike average of the membrane potential of secondary MVN neurons triggered from spikes of single type II neurons. Thus, the inhibitory action originating from burst activity of type II MVN neurons contributes to suppression of type I premotor MVN neurons during fast eye movements.