Parinaud Syndrome

What is Parinaud Syndrome?

The term Parinaud Syndrome use as a reference of multiple eye abnormalities related to eye movement and dysfunctional pupil. Usually affected patient has some history of eye problems, including unexpected onset of binocular, torsional, vertical and diplopia.^1,2 Alternatively, Parinaud Syndrome is also known as dorsal midbrain syndrome.^[2]

Discussion

Parinaud Syndrome or dorsal midbrain syndrome often associated with bilateral superior oblique palsy and both these condition lead to oscillopsia, diplopia, and head posture abnormality.

The multiple problems associated with Parinaud Syndrome are due to arteriovenous malformation. Any brain brainstem hemorrhage which affects the region between ponto-mesencephalic junction to rostral midbrain involving the cerebral peduncles may initiate Parinaud’s Syndrome^.2,3,4

History

The name of this syndrome originated from a French ophthalmologist, Henri Parinaud (1844–1905). Henri Parinaud deemed as the father of French ophthalmology.¹

Signs & Symptoms

Parinaud’s Syndrome is an eye related problems and during the examination of the eye, the following components are usually estimated. Depending upon the frequency of the observed signs found in Parinaud’s Syndrome are divided into two groups – Primary components and secondary components.^1,4,5

Primary components

Disturbance of the Vertical gaze

Descending gaze is typically conserved. but the supranuclear condition arises in The vertical palsy. This cause head maneuver, which leads to elevation of the eyes and consequently mechanism failure observed in all upward gaze^1,2,5,6.

Pseudo-Argyll Robertson pupils

Development of the accommodative paresis, mid- dilation and light-near dissociation occur in pupils^1,2,5,6.

Convergence retraction nystagmus

This phenomenon is produced due to endeavor at upward gaze. Pulling of eyes and retracing of globes can also develop due to hasty up-gaze. The simple approach to overcoming this reaction is following of downward departing stripes on an optokinetic drum^1,2,5,6.

Lid retraction (Collier’s sign)

Retraction of the eyelid can be unilateral or bilateral. J Collier first described this condition in 1972, therefore the condition is also known as Collier’s sign. ^1,2,5,6,7.

“Setting-sun sign”

The condition is also known as conjugate down gaze in the primary position. This is common in patients with botched ventriculoperitoneal shunts^1,2,5,6.

Secondary Components

• Convergence of spasm or paresis
• Accommodation of spasm or paresis
• Thalamic esotropia or pseudoabducens palsy
• Associated Ocular Motility Deficits
• Skew divergence
• Nerve palsy at third position
• Internuclear ophthalmoplegia
• See-saw nystagmus^1,2

The following symptoms patients can experience due to Parinaud’s Syndrome:

• Difficulty in upwards direction gazing
• Diplopia
• near vision becomes blurred
• Oscillopsia
• Associated symptoms related to neurological²

Causes

The etiology of the disease mainly associated with pineal gland tumors and midbrain infarction. Apart from these, two epidemiological cause may associate with Parinaud Syndrome, these are:

• Intermittent or sporadic
• Disease related: Some diseases are involved in the development of the Parinaud’s Syndrome, which includes mesencephalic hemorrhage, obstructive hydrocephalus, A/V malformation, pineal tumors responsible for compression, multiple sclerosis, and trauma^2,7,8.

Diagnosis

Multiple neuroimaging tools, including MRI scan, CT scan, and others are required to diagnosis and treatment procedure of the Parinaud’s Syndrome and to determine the underlying cause of midbrain lesion.

For detail disease progression study, an angiography is required to estimate arteriovenous malformation^2,3,4,5,6.

Treatment

• The treatment is based on diagnosis, which estimates the underlying cause of the disease.
• After detection of underlying cause treatment of the specific cause can be the effective treatment option available for this.
• In most of the cases, surgical intervention requires correcting the underlying condition^2,3,4,5,6.

References

1. E NEUROSURGERY: ESSENTIAL INFORMATION FOR THE BUDDING NEUROSURGEON; Online available; Retrieve from: http://www.eneurosurgery.com/parinaudssyndrome.html
2. Bhola R, Keech RV, Olson RJ: Dorsal Midbrain Syndrome (Parinaud’s Syndrome) with Bilateral Superior Oblique Palsy: 43-year-old male referred for evaluation of binocular diplopia. February 21, 2005; Available from: http://webeye.ophth.uiowa.edu/eyeforum/case21.htm.
3. Lee AG, Brown DG, Diaz PJ. Dorsal midbrain syndrome due to mesencephalic hemorrhage. Case report with serial imaging. J Neuroophthalmol. 1996 Dec;16(4):281-5.
4. Sand JJ, Biller J, Corbett JJ, Adams HP et al. Partial mesencephalic hemorrhages. Neurology.1986 Apr;36(4):529-33.
5. Tachibana H, Mimura O, Shiomi M, Oono T. Bilateral trochlear nerve palsies from a brainstem hematoma. J Clin. Neuro-ophthalmol.1990 March;10(1):35-37.
6. Weisberg LA. Mesencephalic hemorrhages: Clinical and computed Tomographic correlations. Neurology. 1986 May;36(5):713-6.
7. Allmer DM1, Golis TA.; Dorsal midbrain syndrome secondary to a pineocytoma; Optometry. 2001 Apr;72(4):234-8; Online available; Retrieve from: http://www.ncbi.nlm.nih.gov/pubmed/11338448
8. Buckley EG1, Holgado S.; Surgical treatment of upgaze palsy in Parinaud’s syndrome; J AAPOS. 2004 Jun;8(3):249-53; Online available; Retrieve from: http://www.ncbi.nlm.nih.gov/pubmed/15226726