What is the appropriate management for a patient with downward gaze (inferior gaze palsy)?

Management of Downward Gaze Palsy in Intracerebral Hemorrhage (ICH)

Immediate neuroimaging with brain MRI (including high-resolution T2-weighted sequences of the brainstem) is mandatory to confirm the extent of midbrain-thalamic involvement, followed by acute stroke management protocols and supportive care. 1

Immediate Assessment and Neuroimaging

Downward gaze palsy is a specific indicator of central pathology requiring immediate investigation, even if the remainder of the neurological examination appears normal. 1 The anatomical localization is critical:

• Bilateral lesions involving the rostral mesencephalon near the interstitial nucleus of Cajal (INC) cause isolated downward gaze palsy 2
• Bilateral lesions of the dorsomedial red nucleus (including the fasciculus retroflexus) produce selective failure of downward gaze with intact upward gaze 3
• Obtain urgent MRI brain with high-resolution T2-weighted sequences of the brainstem to confirm bilateral thalamic or midbrain infarction 1
• Standard CT may miss small thalamic-mesencephalic lesions, making MRI essential 1

Acute Phase Management Protocol

Stroke Management

• Apply standard acute ischemic stroke management including consideration of thrombolysis if within appropriate time window and no contraindications exist 1
• Maintain cerebral perfusion pressure >60 mmHg through volume replacement and/or catecholamines if necessary 1
• Implement strict blood glucose control, treatment of hyperthermia, and early enteral nutrition 1

Neurological Assessment

• Assess both vertical saccades and smooth pursuit, vestibular eye movements, and horizontal gaze to distinguish supranuclear from nuclear causes 1
• Horizontal eye movements are typically preserved in isolated downward gaze palsy from rostral midbrain lesions 2

Management of Symptomatic Diplopia

For patients with symptomatic vertical diplopia from downward gaze palsy, prism correction may be necessary for persistent deficits. 1

Optical Management Options

• Small vertical deviations can be managed with prism glasses, though lateral incomitance may limit successful implementation 4, 1
• High bifocal segments can alleviate diplopia specifically in the reading position (down gaze at near) 5
• Single-vision readers may be effective for patients symptomatic only during near tasks 5
• Fresnel prisms provide temporary correction while awaiting potential recovery 5

When Surgical Intervention May Be Considered

• Surgery is rarely indicated in acute central downward gaze palsy, as the primary pathology is supranuclear rather than muscular 4
• If persistent vertical deviation develops after recovery, posterior fixation of the contralateral inferior rectus muscle or bilateral inferior rectus recession may be considered 5
• Surgical intervention should not be scheduled earlier than 12 months after onset to allow for potential neurological recovery 6

Rehabilitation Phase

• Initiate early rehabilitation in the intensive care unit once the patient is stable 1
• Progressive mobilization should begin after resolution of acute phase and absence of signs of significant intracranial hypertension 1

Critical Pitfalls to Avoid

• Do not assume benign etiology: vertical gaze palsy mandates immediate neuroimaging regardless of otherwise normal examination 1
• Do not delay high-resolution brainstem MRI, as standard CT is insufficient for detecting small midbrain-thalamic lesions 1
• Do not pursue surgical correction of extraocular muscles in acute phase, as the pathology is supranuclear and may improve with time 1, 6
• Do not overlook that sudden, permanent selective failure of downward gaze accompanied by transient disturbance of consciousness suggests an embolic syndrome of the posterior thalamosubthalamic or rubral artery 3