It is also commonly associated with bilateral papilledema. Neurosurgeons will often see this sign most commonly in patients with failed ventriculoperitoneal shunts. The easiest way to bring out this reaction is to ask the patient to follow down-going stripes on an optokinetic drum.Įyelid retraction (Collier’s sign) Conjugate down gaze in the primary position: “setting-sun sign”.
On fast up-gaze, the eyes pull in and the globes retract. Pseudo-Argyll Robertson pupils: Accommodative paresis ensues, and pupils become mid-dilated and show light-near dissociation.Ĭonvergence-Retraction nystagmus: Attempts at upward gaze often produce this phenomenon. This vertical palsy is supranuclear, so doll’s head maneuver should elevate the eyes, but eventually all upward gaze mechanisms fail. Paralysis of upgaze: Downward gaze is usually preserved. Parinaud’s Syndrome is a cluster of abnormalities of eye movement and pupil dysfunction, characterized by: Parinaud’s syndrome, includes multiple clinical signs, with the most prominent being paralysis of upward gaze. This case demonstrates the imaging features of tumefactive venous infarction in SIH and highlights the risk of misinterpretation as a neoplasm with potentially catastrophic consequences 7). However, this patient underwent a brainstem biopsy, which in retrospect may have been avoidable. The patient was ultimately diagnosed with tumefactive venous infarction secondary to SIH.
#Pseudo argyll robertson pupil paurinaud serial#
Isolated Oculomotor Nerve Nucleus Infarct 5).Ī case of longstanding, undiagnosed spontaneous intracranial hypotension (SIH) with an acute presentation of Parinaud’s syndrome, in whom serial imaging demonstrated development of a midbrain mass. Vertical supranuclear ophthalmoplegia has also been associated with metabolic disorders, such as Niemann-Pick disease, Wilson’s disease, kernicterus, and barbiturate overdose. Neoplasms and giant aneurysms of the posterior fossa have also been associated with the midbrain syndrome. Older patients following stroke of the upper brainstem However, any other compression, ischemia or damage to this region can produce these phenomena: obstructive hydrocephalus, midbrain hemorrhage, cerebral arteriovenous malformation, trauma and brainstem toxoplasmosis infection. A video demonstrates a convergence-retraction nystagmus on upgaze and failure of accommodation, and her brain imaging confirms a corresponding pre-tectal contrast enhancing T2 hyperintense lesion suggestive of demyelination 4). Women in their 20s-30s with multiple sclerosis.Ī 26 year old Pakistani lady with first presentation of a demyelinating event, presenting as Parinaud’s syndrome. Pineal region tumor: Pinealoma (intracranial germinomas) are the most common lesion producing this syndrome). Gradual benign loss of upgaze in senescence.Ĭlassically, it has been associated with three major groups: Stroke or brainstem hemorrhage in the upper part.
Conveniently, a popular mnemonic to remember Argyll Robertson pupils is that, just like prostitutes, they "accommodate but do not react".Parinaud’s Syndrome results from injury, which compresses the the quadrigeminal plate at the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF), specifically, compression or ischemic damage of the mesencephalic tectum, including the superior colliculus adjacent oculomotor (origin of cranial nerve III) and Edinger-Westphal nuclei, causing dysfunction to the motor function of the eye.Ī dilated suprapineal recess can compress the mesencephalic tectum, due to hydrocephalus. Named after Douglas Argyll Robertson (1837–1909), a Scottish surgeon and ophthalmologist, who first described this condition in mid-1860s in patients with neurosyphilis.Īrgyll Robertson pupils are also sometimes called "prostitute's pupils" because of their association with late neurosyphilis. The exact anatomical lesion behind this phenomenon is unknown but is thought to be caused by bilateral damage of the pretectal nuclei in the midbrain. When seen in these non-syphilitic etiologies, the pupil is termed ' pseudo-Argyll Robertson pupil' 3. It is a highly specific sign of late neurosyphilis, however can also occur in diabetic neuropathy, multiple sclerosis, alcoholic midbrain degeneration, and stroke 2,3. Argyll Robertson pupil is usually bilateral and presents as bilaterally miotic and irregular pupils, which constrict briskly with accommodation but do not react to bright light therefore displaying light-near dissociation 1.
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