Abstract

Internuclear ophthalmoparesis (INO) is one of the most common and exquisitely localizing brainstem syndromes in patients with multiple sclerosis (MS). The authors imaged the medial longitudinal fasciculus (MLF) in 58 patients with MS and chronic INO to determine which MRI technique best shows the characteristic lesion associated with this ocular motor syndrome. Using quantitative infrared oculography, the authors determined the ratios of abduction to adduction for velocity and acceleration, to confirm the presence of INO and to determine the severity of MLF dysfunction in the 58 patients with MS and INO. Conventional MRI techniques, including proton density imaging (PDI), T2-weighted imaging, and fluid-attenuated inversion recovery (FLAIR) imaging, were used to ascertain which technique best shows MLF lesions within the brainstem tegmentum. T1-weighted imaging was performed to determine the frequency of brainstem tegmentum hypointensities. All patients studied had evidence of an MLF lesion hyperintensity on PDI, whereas T2-weighted imaging and FLAIR imaging showed these lesions in 88% and 48% of patients, respectively. With PDI, dorsomedial tegmentum lesions were seen in the pons in 93% of patients and in the midbrain of 66% of patients. Lesions were observed at both locations in 59% of patients. Only one patient had an MLF lesion with a corresponding T1 hypointensity. A number of the cases of INO identified oculographically were not evident on clinical examination and many patients suspected of having unilateral INO were found to have bilateral INOs on oculography. Amongst the conventional MRI techniques available, proton density imaging best shows the MLF lesions associated with INO in patients with MS.—Nancy J. Newman

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