目前对于支配眼球垂直运动的神经调控通路没有完全研究清楚。但通常认为眼球垂直凝视的皮质下中枢及其传导通路位于中脑,中脑病变及丘脑病变扩延至中脑水平均可引起垂直眼球凝视障碍。常见表现为4种综合征。 1 Parinaud’s syndrome 2 Vertical ‘half-and-a-half’ syndrome 3 Vertical ‘one-and-a-half’ syndrome 4 Vertical ‘one-and-a-one’ syndrome 1、Parinaud’s syndrome Parinaud 综合征,或者叫中脑背侧综合征、顶盖前区综合征或后联合综合征。临床表现为双眼上视麻痹(如下图)。 中脑与眼球垂直运动相关结构主要有:内侧纵束头端间质核(riMLF)、Cajal间质核(interstitial nucleus of Cajal,INC)、后连合(posterior commissure,PC)。riMLF主要参与垂直扫视,INC参与垂直凝视和维持注视,PC使双眼活动同步。其结构位置如下图所示: 上视传导路径如下图:riMLF内神经元发出垂直扫视指令,INC内神经元发出垂直追踪指令,传导纤维在后联合部位交叉,投射到双侧动眼神经核的相应部分。当后联合相关区域病变时,患者出现双侧上视麻痹。 病例1:肿瘤压迫后联合 病例2:left poseromedial thalamic infarct 病例3:left paramedian midbrain lacunar stroke 2、Vertical ‘half-and-a-half’ syndrome 临床表现为病变同侧下视麻痹伴对侧上视麻痹。 正常垂直扫视传导通路为:riMLF内神经元发出垂直扫视指令后,上视扫视纤维通过后联合交叉传导至对侧动眼神经上直肌核,支配上直肌,下视扫视纤维在同侧下行至同侧动眼神经下直肌核,支配下直肌。完成垂直扫视。如下图所示: 当出现后联合交叉前病变时,出现同侧下视麻痹合并对侧上视麻痹,如图所示: 病例1:a small stroke restricted to the thalamic-mesencephalic junction 病例2:a small thalamomesencephalic stroke 3、Vertical ‘one-and-a-half’ syndrome “垂直一个半综合征”,常表现为一眼上视麻痹,双眼下视麻痹。 当病变累及riMLF及后联合交叉时,可表现出同侧上视、下视麻痹伴有对侧上视麻痹,传导通路及病变位置如下图: 病例:left periventricular mesodiencephalic infarct (a)axial FLAIR and (b)diffusion-weighted image showing left periventricular mesodiencephalic infarct at the bottom of the third ventricle. 4、Vertical ‘one-and-a-one’ syndrome 临床表现为双眼均不能上视或下视,影像学表现常为单侧病变,具体机制不明,有待进一步研究明确,仅将病例列举如下: 病例1:Brain magnetic resonance imaging-diffusion-weighted imaging axial view (a and b) bright signal change in the right paramedian midbrain and anteromedial thalamus (red arrow); apparent diffusion coefficient axial view (d and e) corresponding dark signal change (red arrow); magnetic resonance angiography of intracranial arteries shows thinning of right posterior cerebral artery (red arrow)(c) 病例2:Brain magnetic resonance imaging-diffusion-weighted imaging axial view (a) bright signal change in left anteromedial thalamus (red arrow); apparent diffusion coefficient axial view (b) corresponding dark signal change (red arrow)。magnetic resonance angiography of intracranial arteries shows no abnormality (c) 病例3:Brain magnetic resonance imaging-diffusion-weighted imaging axial view (a) bright signal change in the left thalamus (red arrow) and occipital cortex; magnetic resonance angiography (b) shows thinning of both osterior cerebral artery。 病例4:(a) T2 axial and (b) diffusion MRI of the midbrain. The arrows indicate the ischemic lesion at caudal (left) and rostral (right) midbrain levels. 参考文献 [1] Serino J;Martins J;Páris L;Duarte A;Ribeiro I.Parinaud's syndrome due to an unilateral vascular ischemic lesion.[J]. International Ophthalmology .2015, Vol. 35(No.2):275-279. [2] Rojas P1;Maeder P1;Borruat FX2..Teaching Video NeuroImages: Minimal anomalies of dorsal midbrain syndrome (Parinaud syndrome).[J]. Neurology. 2017,Vol.88(No.1):e8. [3] Priscilla Xinhui Wang and Srinivasan Sanjay.Parinaud Syndrome in Association with Thalamic Infarct in a Young Person [J]. Ophthalmology Research: An International Journal.2014, Vol. 2 (No.5) :241-249 [4] Rechdi Ahdab;Naji Riachi.Vertical ‘half-and-a-half’ syndrome [J].JNNP.2012,Vol.83(No.8):834-835 [5] Sato Kota;Takahashi Yoshiaki;Matsumoto Namiko;Yunoki Taijun; Takemoto Mami;Hishikawa Nozomi; Ohta Yasuyuki; Yamashita Toru;Abe Koji. Rare valiant vertical one-and-a-half syndrome without ipsilateral upward gaze palsy in a patient with thalamomesencephalic stroke.[J].Neurology and clinical neuroscience. 2018 ,(No.5):133-135 [6] Deleu, Dirk.Vertical one-and-a-half syndrome with contralesional pseudo-abducens palsy in a patient with thalamomesencephalic stroke.[J].Journal of the Neurological Sciences.2012,Vol.312(No.1-2):180-183. [7] Rohan R Mahale;Kiran Buddaraju;Anish Mehta;Mahendra Javali; Purushottam Acharya;Rangasetty Srinivasa.Acute bilateral supranuclear vertical gaze palsy: Vertical one-and-a-one syndrome – Report of three cases[J].Journal of Neurosciences in Rural Practice.2017,Vol.8(No.2):313-316. [8] Alemdar M;Kamaci S;Budak F..Unilateral midbrain infarction causing upward and downward gaze palsy[J].J Neuroophthalmol. 2006,Vol.26(No.3):173-176. [9] 何祥.脑干和小脑卒中病人眼球运动异常[J].现代康复杂志.2001,(9A):68-69. |
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