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Desai et al. CASE REPORT
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Vertical upbeat nystagmus with isolated acute middle
cerebellar peduncle stroke
Kinjal Desai, Thomas Bullock, Rahul Damani, Eric Bershad
CASE REPORT
A 68-year-old female with diabetes mellitus,
hypertension,
hyperlipidemia
presents
with
hypertensive urgency, severe nausea, vomiting, and
visual impairment. Initial blood pressure was 236/110
mmHg. She had a Glasgow Coma Scale of 15 and
National Institute of Health Stroke Scale (NIHSS) of 3
(1 gaze impairment, 1 face weakness and 1 sensory loss).
Neurological examination was significant for binocular
vertical diplopia in all directions of gaze, worse on far
gaze. She also had left lateral rectus weakness, left
skew deviation, right hypertropia and a characteristic
vertical upbeat nystagmus (left eye more than right
eye), which was mostly evident in up and leftward gaze
(Video 1). Routine laboratory testing for complete blood
count, basic metabolic panel, and cardiac enzymes
was unremarkable except for blood glucose of 260.
Head computed tomography scan showed no acute
abnormality. Brain magnetic resonance imaging scan
(Figure 1) demonstrated an acute infarct in the medial
aspect of left middle cerebellar peduncle. Her remaining
workup, including magnetic resonance angiogram of
head and neck and cardiac echo was unremarkable.
The etiology of her ischemic stroke were thought to be
related to small vessel disease.
Kinjal Desai, MD, MPH1; Thomas Bullock, MD2; Rahul
Damani, MD, MPH1; Eric Bershad, MD1
Affiliations: 1Baylor College of Medicine, Division of Neurocritical Care; 2Baylor College of Medicine, Department of
Neurology.
Corresponding Author: Kinjal Desai, Baylor College of Medicine, Division of Neurocritical Care, 6301 Almeda Road,
Apt 728, Houston, Texas 77021; E-mail: Kinjal.desai@bcm.
edu
Received: 03 June 2016
Accepted: 03 August 2016
Published: 05 November 2016
Video 1: Vertical upbeat nystagmus video in a patient with
middle cerebellar peduncle stroke.
[Video URL at: http://www.videojournalofneurology.com/
archive/early-view-videos/01_VNP01_2016060001_CV_
EV/01_VNP01_2016060001_CV_EV.php].
Figure 1: Diffusion weighted imaging/Apparent diffusion
coefficient images of ischemic stroke in the left middle cerebellar
peduncle.
Anatomy and Localization
Cerebellum is connected to brainstem by three
bilaterally paired cerebellar peduncles [1]. The superior
cerebellar peduncle which connects to Midbrain contains
efferent fibers from the dentate, emboliform, globose and
fastigial nucleus. The superior cerebellar artery supplies
it. The inferior cerebellar peduncle is located medial to
middle cerebellar peduncle (MCP) and comprised of an
outer restiform body and medial juxtarestiform body.
The inferior cerebellar peduncle connects to medulla
oblongata and is supplied by posterior inferior cerebellar
artery. The MCP connects to Pons and is the most
lateral and largest of three peduncles [2]. It contains
corticopontine fibers from contralateral side that crosses
in pons as transverse pontine fibers and enters MCP to
form the mossy fiber pathway. It also receives fibers from
pontine tegmental nuclei [1]. The superior cerebellar and
anterior inferior cerebellar artery supplies MCP.
In our case, given the location of acute ischemic
stroke, i.e. medial aspect of MCP, the vertical nystagmus
Video Journal of Neurology, Vol. 1, 2016.
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Desai et al. is likely related to fibers traversing through it. The MCP
carries information to and from cerebellum (between
flocculus and nucleus reticularis tegmenti pontes), which
contains vertical pursuit signals encoded with a torsional
component [14, 15].
Per Dr Cogan, vertical eye movement disorders can be
seen with lesions of anterior vermis, middle vermis, roof
nuclei and ocular motor centers located in the floor of the
fourth ventricle. The neocerebellum i.e., pontocerebellum
contains the declive, folium and tuber which are parts of
the midline cerebellar vermis. These tracts then extend
into lateral cerebellar hemisphere. A lesion to the roof of
the fourth ventricle will often result in skew deviation, as
can been seen on the MRI images [2–6].
DISCUSSION
Ocular findings are common in cerebellar disease
in association with brainstem involvement; however,
those that are isolated due to purely cerebellar
involvement are not common [3]. The classic ocular
manifestation of cerebellar disease is nystagmus, skew
deviation, dysmetria and flutter-like oscillations of the
eye. Nystagmus is often seen in acute cerebellar disease
but is not uncommon in chronic conditions affecting
cerebellum [3]. Horizontal nystagmus is more common
than vertical or rotatory nystagmus [3]. Vertical
nystagmus is greatest when gaze is directed upward. It
is associated with jerky rhythmic eye movements [7] and
gross weakness of conjugate gaze to the side of lesion
[8, 9]. Nystagmus due to lesions of the vermis is usually
vertical but less conspicuous [3]. Upbeat nystagmus
from a lesion in brainstem usually involves the ventral
tegmental tract in the pons and caudal medulla [10].
The ventral tegmental tract originates from superior
vestibular nucleus and courses through ventral pons
and transmits excitatory upward vestibular signals
to the oculomotor nerve nucleus [10]. Gaze-evoked
upbeat nystagmus localizes to interstitial nucleus of
Cajal in upper midbrain and occasionally to the nucleus
intercalatus of Staderini [11, 12].
The nucleus prepositus hypoglossi, medial
vestibular nuclei, interstitial nucleus of Cajal and
vestibulocerebellum are important for holding the
eyes steady in eccentric gaze and form the neural
integrator for eye movements [13]. Damage to any of
these structures could potentially result in an upbeat
or downbeat vertical nystagmus. Diseases involving
bilateral middle cerebellar peduncle have been
described, for example, degenerative diseases, metabolic
diseases (adrenoleukodystrophy, Wilson disease,
hypoglycemic coma), neoplasms (brainstem glioma,
meningeal carcinomatosis), cerebrovascular disease
due to AICA infarction, hypertensive encephalopathy
and demyelinating disorders [16].
2
CONCLUSION
A similar case has not been reported before based
on our literature search. We present an interesting case
of vertical upbeat nystagmus in a patient with isolated
middle cerebellar peduncle acute ischemic stroke.
Keywords: Brainstem, Cerebellar disease, Erebellar peduncle stroke, Middle cerebellar peduncle, Vertical upbeat nystagmus
How to cite this article
Desai K, Bullock T, Damani R, Bershad E. Vertical
upbeat nystagmus with isolated acute middle
cerebellar peduncle stroke. Video J Neurol 2016;1:1–
4.
Article ID: 100001VNP01KD2016
*********
doi:10.5348/VNP01-2016-1-CV-1
*********
Author Contributions
Kinjal Desai – Substantial contributions to conception
and design, Acquisition of data, Analysis and
interpretation of data, Drafting the article, Revising
it critically for important intellectual content, Final
approval of the version to be published
Thomas Bullock – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Rahul Damani – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Eric Bershad – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Guarantor
The corresponding author is the guarantor of submission.
Conflict of Interest
Authors declare no conflict of interest.
Copyright
© 2016 Kinjal Desai et al. This article is distributed under
the terms of Creative Commons Attribution License which
permits unrestricted use, distribution and reproduction in
any medium provided the original author(s) and original
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Desai et al. publisher are properly credited. Please see the copyright
policy on the journal website for more information.
9.
10.
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ABOUT THE AUTHORS
Article citation: Desai K, Bullock T, Damani R, Bershad E. Vertical upbeat nystagmus with isolated acute middle
cerebellar peduncle stroke. Video J Neurol 2016;1:1–4.
Kinjal Desai is a Neurocritical Care Senior Fellow at Baylor College of Medicine in the Department
of Vascular Neurology and Neurocritical Care in Houston, Texas, USA. He earned undergraduate
Medical Degree MBBS from India at Smt. NHL Municipal Medical College and Residency Training
from University of Mississippi Medical Center in Jackson, MS after a Graduate Degree in MPH
from University of Southern Mississippi in Hattiesburg, MS. He has published multiple posters,
given multiple oral presentations and has worked on book chapters, peer review journals including
publications. His research interests include status epilepticus, neuroradiology, stroke and bedside
ultrasound. He intends to pursue further training to complete his Doctorate in Public Health upon
completion of his neurocritical care training.
E-mail: [email protected]
Thomas Bullock is a faculty in Baylor College of Medicine, Department of Neurology.
Rahul Damani is a faculty in Baylor College of Medicine, Division of Neurocritical Care.
Video Journal of Neurology, Vol. 1, 2016.
Video J Neurol 2016;1:1–4.
www.videojournalofneurology.com
Desai et al. Eric Bershad is a faculty in Baylor College of Medicine, Division of Neurocritical Care.
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