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Internuclear ophthalmoplegia plus ataxia indicates a dorsomedial tegmental lesion at the pontomesencephalic junction

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Abstract

Internuclear ophthalmoplegia (INO) indicates a lesion involving the medial longitudinal fasciculus (MLF) that interconnects the abducens nucleus and medial rectus subnucleus of the oculomotor nuclear complex. In fact, rostral-caudal localization value of the INO is often limited except when it accompanies symptoms and signs owing to involvement of nearby structures. Ataxia is often observed in lesions involving the cerebellum or the fibers to and from it anywhere in the brainstem. Herein, we sought to determine the localizing value of INO plus ataxia in the rostrocaudal axis of the brainstem. Thirty patients with INO plus limb or truncal ataxia were subjected to analyses. For comparison, 20 patients with isolated INO without any ataxia served as the control. We determined the lesion extent in the MRIs responsible for INO plus ataxia using a probabilistic lesion mapping and subtraction analysis and analyzed the neuro-otologic findings using video-oculography. In patients with INO with limb or truncal ataxia, the responsible lesions were mostly restricted to the paramedian tegmentum at the pontomesencephalic junction. In contrast, the lesions causing isolated INO without ataxia were mostly located in the caudal or mid-pontine area. The rostro-caudal distribution of the lesions was similar among the patients with only limb ataxia (n = 3), both limb and truncal ataxia (n = 10), and only truncal ataxia (n = 17). INO plus ataxia indicates a lesion involving the MLF at the pontomesencephalic junction. Damage to the brachium conjunctivum or mesencephalic locomotor region may explain the ataxia in association with INO in lesions involving this area.

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Acknowledgments

Dr. Lee had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors thank Sung-Jin Jo for providing the illustration. This study was supported by a grant of the Korea Healthcare technology R&D Project, Ministry of Health and Welfare, Republic of Korea (HI10C2020).

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Authors and Affiliations

  1. Department of Neurology, Ajou University School of Medicine, Ajou University Hospital, Suwon, South Korea

    Sun-Uk Lee

  2. Department of Biomedical Laboratory Science, Kyungdong University, Goseong-gun, Gangwon-do, South Korea

    Hyo-Jung Kim

  3. Department of Neurology, Konkuk University School of Medicine, Konkuk University Hospital, Seoul, South Korea

    Jeong-Jin Park

  4. Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea

    Ji-Soo Kim

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  1. Sun-Uk Lee
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Correspondence to Ji-Soo Kim.

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Conflicts if interest

SU Lee, HJ Park, and JJ Park report no disclosures. JS Kim serves as an Associate Editor of Frontiers in Neuro-otology and on the editorial boards of the Journal of Clinical Neurology, Frontiers in Neuro-ophthalmology, Journal of Neuro-ophthalmology, Journal of Vestibular Research, Journal of Neurology, and Medicine, and received research support from SK Chemicals, Co. Ltd

Study ethics

All experiments followed the tenets of the Declaration of Helsinki and this study was approved by Institutional Review Board of Seoul National University Bundang Hospital (B-1105/127-110).

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Lee, SU., Kim, HJ., Park, JJ. et al. Internuclear ophthalmoplegia plus ataxia indicates a dorsomedial tegmental lesion at the pontomesencephalic junction. J Neurol 263, 973–980 (2016). https://doi.org/10.1007/s00415-016-8088-1

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  • DOI: https://doi.org/10.1007/s00415-016-8088-1

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