title: Unilateral INO is associated with ocular tilt reaction in pontomesencephalic lesions: INO plus.
abstract: OBJECTIVE
  Correlation of internuclear ophthalmoplegia (INO) with components of the ocular tilt reaction (OTR) in order to localize graviceptive (specifically otolithic) pathways in the brainstem.
  
  
  METHODS
  We retrospectively analyzed data of 120 patients with INO (87 unilateral [9 of whom had one-and-a-half syndrome], 33 bilateral) for OTR (subjective visual vertical [SVV], ocular torsion, skew deviation) to localize causative brainstem lesions in MRI.
  
  
  RESULTS
  Unilateral INO was accompanied by at least one component of OTR: SVV tilt in 96%, ocular torsion in 79%, and skew deviation in 50%. All components were directed to the contralesional side. Contralateral OTR occurred in 89% of patients with one-and-a-half syndrome. Only 9% of patients with bilateral INO exhibited OTR. MRI showed distinct lesions in 68%, which almost exclusively projected onto the pontomesencephalic medial longitudinal fascicle (96%). Follow-up measurements revealed SVV and ocular torsion normalized faster than the adduction deficit in INO.
  
  
  CONCLUSIONS
  First, unilateral internuclear ophthalmoplegia (INO) is regularly associated with contraversive ocular tilt reaction (OTR): INO plus. Thus, graviceptive pathways join the medial longitudinal fascicle after crossing between the vestibular and abducens nuclei. Second, the different time course and degree of recovery of OTR components and INO signs can be explained by the hypothesis that vestibular tone imbalance is compensated by central vestibular adaptation mechanisms (probably driven mainly by cerebellar-vestibular projections), whereas impaired adduction is less susceptible to compensation according to Hering's law and can only be overcome by lesion repair. Third, bilateral INO is seldom associated with OTR, confirming that bilateral impairment of graviceptive pathways does not cause imbalance in roll plane.
authors: Department of Neurology, University of Munich, Klinikum Grosshadern, Marchioninistrasse 15, D-81377 Munich, Germany. andreas.zwergal@med.uni-muenchen.de
authors: A
authors: A
authors: Zwergal
authors: C
authors: C
authors: Cnyrim
authors: V
authors: V
authors: Arbusow
authors: M
authors: M
authors: Glaser
authors: G
authors: G
authors: Fesl
authors: T
authors: T
authors: Brandt
authors: M
authors: M
authors: Strupp
mesh_terms: D000222:Adaptation, Physiological; D000328:Adult; D000368:Aged; D020520:Brain Infarction / Q000150:complications / Q000473:pathology / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D007839:Functional Laterality; D018466:Gravity Sensing; D006801:Humans; D020300:Intracranial Hemorrhages / Q000150:complications / Q000473:pathology / Q000503:physiopathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008636:Mesencephalon / Q000503:physiopathology*; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000150:complications / Q000473:pathology / Q000503:physiopathology; D009434:Neural Pathways / Q000503:physiopathology; D015835:Ocular Motility Disorders / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology*; D011149:Pons / Q000503:physiopathology*; D020127:Recovery of Function; D012189:Retrospective Studies; D013577:Syndrome; D014724:Vestibular Function Tests