The middle cerebellar peduncle (MCP) is a major conduit for cortico-ponto-cerebellar fibers that convey information related to eye movements. This study aims to elucidate eye movement abnormalities that arise from lesions confined to the MCP. In 23 patients with acute strokes restricted to unilateral MCPs, we investigated the clinical features and ocular motor findings including spontaneous nystagmus, saccades, smooth pursuit, ocular tilt reaction, and head impulse tests. Bithermal caloric tests and audiometry were also performed. Patients with strokes restricted to the MCP usually developed acute vertigo or imbalance, along with few sensorimotor signs or auditory symptoms. Patients frequently showed abnormal eye movements that included spontaneous horizontal/torsional nystagmus, ocular tilt reaction, gaze-evoked nystagmus, abnormal head impulse responses, and bilaterally impaired horizontal smooth pursuit. Unilateral MCP strokes produce acute vertigo and imbalance with distinct ocular motor abnormalities, which are primarily caused by damage to the central vestibular structures and by disruption of the neural pathways responsible for eye-position stabilization and smooth pursuit.
This is a preview of subscription content, log in to check access.
Compliance with ethical standards
Conflicts of interest
The authors declare that they have no conflict of interest.
All experiments followed the tenets of the Declaration of Helsinki. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-0910/086-102).
Written informed consents were obtained from the participants.
Glickstein M, May JG, Mercier BE (1985) Corticopontine projection in the macaque: the distribution of labelled cortical cells after large injections of horseradish peroxidase in the pontine nuclei. J Comp Neurol 235:343–359CrossRefGoogle Scholar
Glickstein M, Sultan F, Voogd J (2011) Functional localization in the cerebellum. Cortex 47:59–80CrossRefGoogle Scholar
Turner RS, German WJ (1941) Functional anatomy of brachium pontis. J Neurophysiol 4:196–206CrossRefGoogle Scholar
Matsuda Y, Inagawa T, Amano T (1993) A case of tinnitus and hearing loss after cerebellar hemorrhage. Stroke 24:906–908CrossRefGoogle Scholar
Wizer B, Wall M, Weisberg L (1988) The clinical and computed tomographic features of cerebellar peduncular hemorrhage. Neurology 38:1485CrossRefGoogle Scholar
Vitek L, Tettenborn B (2002) Cavernous angioma in the brachium pontis presenting with trigeminal neuralgia: a case report. Eur Neurol 48:226–228CrossRefGoogle Scholar
Kato I, Takeyama I, Watanabe J et al (1991) EOG findings in patients with lesions in cerebellar peduncles. Acta Otolaryngol Suppl 111:260–261CrossRefGoogle Scholar
FitzGibbon EJ, Calvert PC, Dieterich M, Brandt T, Zee DS (1996) Torsional nystagmus during vertical pursuit. J Neuroophthalmol 16:79–90CrossRefGoogle Scholar
Haines DE (2004) Internal morphology of the brain in slices and MRI. In: Haines DE (ed) Neuroanatomy: An atlas of structures, sections, and systems. Lippincott, Philadelphia, pp 63–81Google Scholar
Choi KD, Oh SY, Park SH, Kim JH, Koo JW, Kim JS (2007) Head-shaking nystagmus in lateral medullary infarction patterns and possible mechanisms. Neurology 68:1337–1344CrossRefGoogle Scholar
Halmagyi GM, Curthoys IS (1988) A clinical sign of canal paresis. Arch Neurol 45:737–739CrossRefGoogle Scholar
Kim HJ, Park SH, Kim JS, Koo JW, Kim CY, Kim YH et al (2016) Bilaterally abnormal head impulse tests indicate a large cerebellopontine angle tumor. J Clin Neurol 12:65–74CrossRefGoogle Scholar
Lee H, Kim JS, Chung EJ et al (2009) Infarction in the territory of anterior inferior cerebellar artery spectrum of audiovestibular loss. Stroke 40:3745–3751CrossRefGoogle Scholar
Amarenco P, Rosengart A, DeWitt LD, Pessin MS, Caplan LR (1993) Anterior inferior cerebellar artery territory infarcts: mechanisms and clinical features. Arch Neurol 50:154–161CrossRefGoogle Scholar
Kim HJ, Lee SH, Park JH, Choi JY, Kim JS (2014) Isolated vestibular nuclear infarction: report of two cases and review of the literature. J Neurol 261:121–129CrossRefGoogle Scholar
Arnold D, Robinson D (1997) The oculomotor integrator: testing of a neural network model. Exp Brain Res 113:57–74CrossRefGoogle Scholar
Seo SW, Shin HY, Kim SH et al (2004) Vestibular imbalance associated with a lesion in the nucleus prepositus hypoglossi area. Arch Neurol 61:1440–1443CrossRefGoogle Scholar
Park HK, Kim JS, Strupp M, Zee DS (2013) Isolated floccular infarction: impaired vestibular responses to horizontal head impulse. J Neurol 260:1576–1582CrossRefGoogle Scholar
Joshua M, Medina JF, Lisberger SG (2013) Diversity of neural responses in the brainstem during smooth pursuit eye movements constrains the circuit mechanisms of neural integration. J Neurosci 33:6633–6647CrossRefGoogle Scholar
Langer T, Fuchs A, Scudder C, Chubb M (1985) Afferents to the flocculus of the cerebellum in the rhesus macaque as revealed by retrograde transport of horseradish peroxidase. J Comp Neurol 235:1–25CrossRefGoogle Scholar
Leigh RJ, Zee DS (2015) Gaze holding and the neural integrator. In: Leigh RJ, Zee DS (eds) The neurology of eye movements, 5th edn. Oxford University Press, New York, pp 360–380Google Scholar
Halmagyi G, Weber K, Curthoys I (2009) Vestibular function after acute vestibular neuritis. Restor Neurol Neurosci 28:37–46Google Scholar
Lee H, Lee S, Lee S, Park B, Baloh R (2005) Ocular tilt reaction and anterior inferior cerebellar artery syndrome. J Neurol Neurosurg Psychiatry 76:1742–1743CrossRefGoogle Scholar
Lee H, Yi HA, Lee SR, Lee SY, Park BR (2008) Ocular torsion associated with infarction in the territory of the anterior inferior cerebellar artery: frequency, pattern, and a major determinant. J Neurol Sci 269:18–23CrossRefGoogle Scholar
Morrow MJ, Sharpe JA (1988) Torsional nystagmus in the lateral medullary syndrome. Ann Neurol 24:390–398CrossRefGoogle Scholar
Brandt T, Dieterich M (1994) Vestibular syndromes in the roll plane: topographic diagnosis from brainstem to cortex. Ann Neurol 36:337–347CrossRefGoogle Scholar
Gerrits N, Epema A, Voogd J (1984) The mossy fiber projection of the nucleus reticularis tegmenti pontis to the flocculus and adjacent ventral paraflocculus in the cat. Neuroscience 11:627–644CrossRefGoogle Scholar
Glickstein M, Gerrits N, Kralj-Hans I, Mercier B, Stein J, Voogd J (1994) Visual pontocerebellar projections in the macaque. J Comp Neurol 349:51–72CrossRefGoogle Scholar
Cicirata F, Zappalà A, Serapide MF et al (2005) Different pontine projections to the two sides of the cerebellum. Brain Res Rev 49:280–294CrossRefGoogle Scholar