Ocular Tilt Reaction: Vestibular Disorder in Roll Plane

Transcription

1 대한안신경의학회지 : 제 8 권 Supplement 1 ISSN: Ocular Tilt Reaction: Vestibular Disorder in Roll Plane Ji-Yun Park Department of Neurology, Ulsan University Hospital, Ulsan, Korea Ocular tilt reaction : vestibular disorder in roll plane Ji-Yun Park Department of Neurology Ulsan University Hospital Roll X Surge Surge Ocular tilt reaction Horizontal nystagmus Yaw Lateropulsion Z Saccadic lateropulsion Heave, Bob Heave, Bob Upbeat nystagmus Downbeat nystagmus - Ocular tilt reaction - SVV tilt : lateral perception and postural tilt Y Sway Pitch Sway Linear acceleration Test of utriculur function (superior division) : OTR ocular torsion, SVV, head tilt : ovemp Head tilt reaction coordinated motion of eye-head roll motion Test of saccular function(inferior division) : cvemp S14 Copyright 2018 The Korean Society of Neuro-Ophthalmology

2 Ocular Tilt Reaction: Vestibular Disorder in Roll Plane Park JY Head tilt reaction Graviceptive pathways electical stimulation of the utricle -> upward-torsional movement of the ipsilateral eye -> downward-torsional movement of the contralateral eye Avia Space Environ Med 1987;58(suppl): A192-A197 Ocular tilt reaction American orthoptic journal, Vol 53, 2003 Ocular tilt reaction Ocular Tilt Reaction (OTR) - Vestibular tone imbalance in the roll plane - dysfunction of graviceptive pathway from peripheral labyrinth to INC of the rostral midbrain 1. Head tilt Skew deviation Head tilt Skew Deviation Nine cardinal photography Cover test Red glass test, maddox rod test Lancaster, Hess test Ocular torsion Fundus photography Subjective visual vertical Graviceptive pathways from peripheral labyrinth to INC of the rostral midbrain contraversive with pontomesencephalic lesions ipsiversive with peripheral & pontomedullary lesions S15

3 Park JY Ocular Tilt Reaction: Vestibular Disorder in Roll Plane Ipsilesional OTR in wallenberg syndrome Descending integrator OTR INC Ascending VOR OTR S16

4 Ocular Tilt Reaction: Vestibular Disorder in Roll Plane Park JY Case presentation: thalamus Roll of cerebellum on otolith system the insular cortex (IC) inferior frontal gyrus (IFG) the superior temporal gyrus (STG) the rolandic operculum the inferior occipitofrontal fascicle the superior longitudinal fascicle Nodulus and uvula General role in the postural control and coordination of the head and body Receive ipsilateral vestibular ganglion & vestibular nuclei Project into directly ipsilateral vesitobular nuclei Unilateral cerebellar lesion(nodulus and uvula) Increase in the tonic resting activity of secondary otolithic neurons in ipsilesional vestibular nucleus Tonic contraversive OTR Otholith dysfunction in PICA infarction Frequency of different signs of vestibular dysfunction in roll plane PICA infarction including nodulus : contralesional imcomplete OTR, SVV tilt PICA infarction sparing nodulus : ipsilesional SVV tilt, falling without accompanying OT or SD interruption of nodular inhibitory projections to graviceptive neurons in the ipsilesional vestibular nuclei caused the contraversive conjugate ocular torsion S17

5 Park JY Ocular Tilt Reaction: Vestibular Disorder in Roll Plane Skew deviation : OTR DDx. with Skew Deviation Elevated eye is intorted (extorted in 4 th N palsy) Head tilt toward undermost eye if exist Hypertropia decreased in supine position Comitant, Negative Bielschowski head-tilt test Hertwig-Magendie Sign Common supranuclear vertical misalignment of the visual axes one of the important signs of central vertigo most of SD are seen in the brainstem or cerebellar lesions a part of the HINTS(Head-Impulse test(hit), Nystagmus, Test of Skew) D/Dx of trochlear nerve palsy <<4 th nerve palsy>> : Hypertropia(lesion) : Extorsion : contra head tilt <<skew deviation>> : Hypertropia (sound) : Intorsion : contra head tilt Case: paroxysmal OTR Case : alternating skew deviation Alternating Skew deviation Cervicomedullary junction or cerebellar pathway lesions Associated downbeat nystagmus 1977 Mossman and Halmagyi Alternating skews related to the otolithic-ocular response to pitch of the head in lateral-eyed animal alternating skews in frontal-eye animal and human in pathological condition to (1) an imbalance in otolithic-ocular pathway (2) a loss of the component of ocular motor innervation that normally corrects for the differences in pulling directions and strengths of the various ocular muscles as the eyes change positions in the orbit This compensatory mechanism may depend on the cerebellum 1996 Zee S18

6 Ocular Tilt Reaction: Vestibular Disorder in Roll Plane Park JY Subjective visual vertical Verticality perception normal subjects can adjust an illuminated rod in an otherwise completely dark room to vertical within a mean error of less than 2 3. Tilts of the SVV Secondary to the vestibular tone imbalance in the roll plane Peripheral and central vestiular lesions from the labyrinth to the vestibular cortex The most sensitive sign of a vestibular tone imbalance in roll plane OT and SVV are usually dissociated in quantity in central vestibular lesions Case presentation:utricle Case1) ipsilateral utricular dysfuction 43, F subjective vertigo & severe postural unsteadiness, vertical diplopia spontaneous RBN, left head tilt, left SD Semicircular function was normal, unilateral otolithic deficits Case 1) unilateral utricular dysfuction Case 2) unilateral saccular dysfunction Case 3) unilateral utricule and saccular dysfunction Case2) ipsilateral saccular dysfuction 42, M subjective vertigo & severe postural unsteadiness, N/V Downbeat spontaneous nystagmus Case3) ipsilateral utricle and saccular dysfuction 14, F rotatory vertigo & N/V F acute vertigo & severe postural unsteadiness mixed hearing loss in the right for 1 year Normal vhit ovemps, cvemps impaired S19

7 Park JY Ocular Tilt Reaction: Vestibular Disorder in Roll Plane OTR: summary S20