Midbrain disorders of vertical gaze: a quantitative re-evaluation

The mesodiencephalic junction is the site of the prenuclear control of vertical eye motion. We measured vertical saccades, smooth pursuit (SP), the vertical vestibulo-ocular reflex (VOR), and its interactions with vision during active head motion in 21 patients with midbrain lesions causing palsy of vertical saccades, upward, downward, or in both directions. Most patients with limited slow or slowed saccades in one direction on clinical examination had slowed saccades in the opposed direction. SP gain was decreased in both directions in most patients, and decreased upward or downward in few. VOR gain was subnormal in both directions in many patients, and upward only in one; phase lead of the VOR was recorded in 33% of them. Subnormal SP and VOR gains were often dissociated. Visually enhanced VOR gains were subnormal in both directions in many patients. Cancellation of the VOR was impaired in many patients, both upward and downward in most and upward in few patients. Gaze (eye plus head) tracking gain was subnormal in 29% of patients. Defective SP and defective cancellation of the VOR during head free tracking were often dissociated. We conclude that VOR and SP gains are usually subnormal in patients with paresis of vertical saccades. Impairment of pursuit and the VOR are often dissociated. Phase lead of the VOR implicates damage to velocity-to-position neural integrator for vertical eye motion. These associations and dissociations of impaired vertical eye motion signify discrete structural and functional effects of supranuclear midbrain damage that are undetected by examination of saccades.