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Patterns of ocular oscillation in oculopalatal tremor

Imaging correlations

From the Division of Neurology (J.S.K., J.A.S.) University Health Network, University of Toronto, Toronto, Canada; Departments of Neurology (J.S.K., S.Y.M., K.-D.C.) and Radiology (J.H.K.), College of Medicine, Seoul National University, Seoul, Korea.

Address correspondence and reprint requests to Dr. James A. Sharpe, Division of Neurology, University Health Network, 399 Bathurst Street, WW5-440, TWH, Toronto, ON, M5T 2S8, Canada; e-mail: sharpej{at}uhnres.utoronto.ca

Objective: To determine patterns of nystagmus in oculopalatal tremor (OPT, also designated oculopalatal myoclonus) and correlate them with MRI changes in the inferior olivary nuclei (ION). Mixed torsional-vertical pendular nystagmus (PN) in OPT has been considered to signify unilateral brainstem damage and symmetric vertical nystagmus considered to indicate bilateral disease.

Methods: Ocular oscillations were analyzed in 22 patients with OPT, 20 from focal brainstem lesions, with or without cerebellar lesions, and two from the progressive ataxia and palatal tremor syndrome. MRI was performed in all patients.

Results: Patients had mainly vertical oscillations with varied combinations of torsional and horizontal components. Fourteen patients had binocular symmetry of PN and eight showed dissociated PN. MRI demonstrated ION signal change, unilateral in 14 and bilateral in eight. Unilateral olivary changes were associated with symmetric PN in six and with dissociated nystagmus in eight patients. Bilateral olivary changes were visible in eight patients with symmetric nystagmus. Dissociated PN was associated with MR pseudohypertrophy of ION on the side of the eye with greater vertical amplitude of oscillation. Notably, four patients never developed palatal tremor despite ION signal change. OPT resolved in one patient after 20 years and was markedly reduced in another patients after 6 years.

Conclusions: Dissociated pendular nystagmus predicted asymmetric (unilateral) inferior olivary pseudohypertrophy on MRI with accuracy, but symmetric pendular nystagmus was associated with either unilateral or bilateral signal changes in the inferior olivary nucleus. Instability of eye velocity to position integration from damage to the paramedian tract projections and denervation of the dorsal cap of the inferior olive are proposed mechanisms of the pendular nystagmus.

Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the April 3 issue to find the title link for this article.

Supported by an Elizabeth Barford Award, University of Toronto (J.S.K.), a grant from the Korea Science and Engineering Foundation R05-2001-000-00616-0 (J.S.K.), and by Canadian Institutes of Health Research grants MT 5404, ME 5909 and MT 15362 (J.A.S.).

Disclosure: The authors report no conflicts of interest.

Received March 16, 2006. Accepted in final form November 30, 2006.

This article has been cited by other articles:

				Y. Aladdin, J. Scozzafava, T. Muayqil, and M. Saqqur Pearls & Oy-sters: Oculopalatal tremor with one-and-a-half syndrome after pontine hemorrhage Neurology, October 14, 2008; 71(16): e39 - e41. [Full Text] [PDF]

				C. E. Watson, J. A. Sharpe, and J. S. Kim PATTERNS OF OCULAR OSCILLATION IN OCULOPALATAL TREMOR: IMAGING CORRELATIONS Neurology, November 27, 2007; 69(22): 2111 - 2111. [Full Text] [PDF]

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