Monocular Torsional Oscillopsia in Dentato-olivary Disconnection

Monocular torsional eye oscillations are a rare form of disconjugate nystagmus and the underlying pathophysiology is not well understood. Here, we present and discuss a case with disabling torsional oscillopsia in one eye only. The patient exhibited (i) spontaneous pendular torsional nystagmus of the left eye and (ii) rhythmic involuntary movements of the soft palate and uvula, consistent with the syndrome of oculopalatal tremor with monocular nystagmus. Brain MRI revealed an infarct of the left dentate nucleus in the cerebellum and, more caudally, a secondary hypertrophic degeneration of the right inferior olivary nucleus. To account for the presence of torsional nystagmus on the eye contralateral to the side of inferior olivary hypertrophy and ipsilateral to the lesioned dentate nucleus, we discuss the hypothesis of a (inferior olivary nucleus-mediated) malfunctioning adaptation of the anterior canal vestibulo-ocular reflex.

Olivary body exposure through far lateral and lower retrosigmoid approaches. Comparative analysis of the exposed surface and angle of attack

OBJECTIVES

Throughout neurosurgical history, the treatment of intrinsic lesions located in the brainstem has been subject of much controversy. The brainstem is the anatomical structure of the central nervous system (CNS) that presents the highest concentration of nuclei and fibers, and its simple manipulation can lead to significant morbidity and mortality. Once one of the safe entry points at the medulla oblongata has been established, we wanted to evaluate the safest approach to the olivary body (the most used safe entry zone on the anterolateral surface of the medulla oblongata). The proposed objective was to evaluate the working channel from the surface of each of the far lateral and retrosigmoid approaches to the olivary body: distances, angles of attack and channel content.

MATERIAL AND METHODS

To complete this work, a total of 10 heads injected with red/blue silicone were used. A total of 40 approaches were made in the 10 heads used (20 retrosigmoid and 20 far lateral). After completing the anatomical study and obtaining the data referring to all the approaches performed, it was decided to expand the sample of this research study by using 30 high-definition magnetic resonance imaging of anonymous patients without cranial or cerebral pathology. The reference points used were the same ones defined in the anatomical study. After defining the working channels in each of the approaches, the working distances, angle of attack, exposed surface, and the number of neurovascular structures present in the central trajectory were analyzed.

RESULTS

The distances to the cranial and medial region of the olivary body were 52.71 mm (SD 3.59) from the retrosigmoid approach and 27.94 mm (SD 3.99) from the far lateral; to the most basal region of the olivary body, the distances were 49.93 (SD 3.72) from the retrosigmoid approach and 18.1 mm (SD 2.5) from the far lateral. The angle of attack to the caudal region was 19.44° (SD 1.3) for the retrosigmoid approach and 50.97° (SD 8.01) for the far lateral approach; the angle of attack to the cranial region was 20.3° (SD 1.22) for the retrosigmoid and 39.9° (SD 5.12) for the far lateral. Regarding neurovascular structures, the probability of finding an arterial structure is higher for the lateral far, whereas a neural structure will be more likely from a retrosigmoid approach.

CONCLUSIONS

As conclusions of this work, we can say that far lateral approach presents more favorable conditions for the microsurgical treatment of intrinsic bulbar and bulbomedullary lesions approached through the caudal half of the olivary body. In those cases of bulbar and pontine-bulbar lesions approached through the cranial half of the olivary body, the retrosigmoid approach can be considered for selected cases.

[A case of Holmes tremor in which 123I-IMP SPECT and MRI findings suggest damage to the cerebellothalamic tract and the dentato-rubro-olivary pathway]

A 75-year-old woman was referred to our department in October 2022 with ataxia and involuntary movements of the right upper and lower limbs. She had experienced a left pontine hemorrhage in March 2021, which was managed conservatively. However, she had residual right-sided hemiplegia. In addition, she had cerebellar ataxia and a 2 ‍Hz resting tremor of the right upper and lower limbs, which was enhanced while maintaining posture and contemplation. Based on her history, and the findings of MRI and nuclear medicine imaging, we diagnosed the patient with Holmes tremor due to pontine hemorrhage. Holmes tremor is a rare movement disorder secondary to brainstem and thalamic lesions, characterized by a unilateral low-frequency tremor. In this case, 123I-IMP SPECT and MRI shows damage to the cerebellothalamic tract and dentaro-rubro-olivary pathway.

Bilateral surgical damage of the central tegmental tract resulting in bilateral hypertrophic olivary degeneration: An MRI case report

Hypertrophic olivary degeneration (HOD) is a rare trans-synaptic neuronal degeneration of the inferior olivary nucleus caused by an injury to the dentato-rubro-olivary connection, also known as Guillain-Mollaret triangle. It leads to hypertrophy of the affected nucleus rather than atrophy and is characterized by hyperintensity on T2-weighted images. Unilateral and bilateral cases are described. We present a case of a 70-year-old patient affected by a tumor inside the fourth ventricle who suffered from diplopia and right seventh cranial nerve palsy. He underwent surgery and developed left seventh cranial nerve palsy. Three months after resection, magnetic resonance imaging revealed the appearance of bilateral HOD. This is the first report of bilateral HOD occurrence after surgical bilateral damage of the rubro-olivary fibers running in central tegmental tracts.

The Olivary Hypothesis of Essential Tremor: Time to Lay this Model to Rest?

BACKGROUND

Although essential tremor (ET) is the most common tremor disorder, its pathogenesis is not fully understood. The traditional model of ET, proposed in the early 1970s, posited that the inferior olivary nucleus (ION) was the prime generator of tremor in ET and that ET is a disorder of electrophysiological derangement, much like epilepsy. This article comprehensively reviews the origin and basis of this model, its merits and problems, and discusses whether it is time to lay this model to rest.

METHODS

A PubMed search was performed in March 2017 to identify articles for this review.

RESULTS

The olivary model gains support from the recognition of neurons with pacemaker property in the ION and the harmaline-induced tremor models (as the ION is the prime target of harmaline). However, the olivary model is problematic, as neurons with pacemaker property are not specific to the ION and the harmaline model does not completely represent the human disease ET. In addition, a large number of neuroimaging studies in ET have not detected structural or functional changes in the ION; rather, abnormalities have been reported in structures related to the cerebello-thalamo-cortical network. Moreover, a post-mortem study of microscopic changes in the ION did not detect any differences between ET cases and controls.

DISCUSSION

The olivary model largely remains a physiological construct. Numerous observations have cast considerable doubt as to the validity of this model in ET. Given the limitations of the model, we conclude that it is time now to lay this model to rest.

Panmedullary edema with inferior olivary hypertrophy in bilateral medial medullary infarction

Bilateral medial medullary infarction (MMI) is a rare type of stroke with poor outcomes. Inferior olivary nucleus hypertrophy results from a pathologic lesion in the Guillain-Mollaret triangle. The relationship between inferior olivary nucleus hypertrophy and the medullary lesion is obscure. To the best of our knowledge, only 1 autopsy case with unilateral medial medullary infarction that was associated with ipsilateral inferior olivary nucleus hypertrophy has been reported. We describe a rare case with acute infarction in the bilateral medial medulla oblongata accompanied by subacute bilateral inferior olivary nucleus hypertrophy and panmedullary edema. The hypertrophy appeared to have been caused by local ischemic damage to the termination of the central tegmental tract at the bilateral inferior olivary nucleus.

Isolated tongue tremor after removal of cerebellar pilocytic astrocytoma: Functional analysis with SPECT study

Tongue tremor is a rare form of focal tremor. Even though the dysfunction of the dentato-rubro-olivary circular pathway has been proposed as its mechanism, the origin of the rhythmic activities remains unknown. We experienced a case of isolated tongue tremor after the removal of a cerebellar pilocytic astrocytoma. To localize the activated structures corresponding to the isolated tongue tremor, we analyzed subtracted ictal SPECT coregistered to MRI (SISCOM). SISCOM demonstrated multiregional hyperperfusion including the Guillain-Mollaret triangular and extratriangular structures. The activation of the inferior olive and red nucleus and accompanying extratriangular structures might be related to the isolated tongue tremor.

Asymmetrical localization of benzodiazepine receptors in the human auditory cortex

In humans, administration of benzodiazepines (BZD) has been shown to have an asymmetrical effect on the medial olivocochlear system. Indeed, a decrease of evoked otoacoustic emission suppression by contralateral acoustic stimulation, which explores the medial olivocochlear efferent system, was observed in the right ear, with no left ear effect. This result suggests a possible left-right auditory pathway BZD receptor asymmetry. Given the anatomical link between auditory centers and the medial olivocochlear system, the existence of a larger volume of cortical connecting fibers in the left hemisphere, and the possible link between BZD receptor density and neuronal density, we tested the hypothesis of an asymmetrical localization of BZD receptors in the auditory system in 10 right-handed subjects using [11C]flumazenil positron emission tomography. Semi-quantitative measurements of flumazenil binding were evaluated in Heschl's gyrus showing a left-right asymmetry in favor of left auditory cortex. This result indicates a higher density of neurons in left auditory cortex. The possible link between neurochemical asymmetry and functional asymmetry, and the perceptual outcome of BZD administration, will be discussed.

Cavernous angioma with olivary hypertrophy and contralateral cerebellar diaschisis

We describe a 66-year-old man with a 20-year history of ataxic gait who suddenly developed diplopia on rightward gaze. Neurologic examination revealed right hemi-ataxia and hemi-hypesthesia, and left internuclear ophthalmoplegia. MRI showed a cavernous angioma in the left tectum, mild right cerebellar atrophy, and left interior olivary hypertrophy. Single photon emission computed tomography (SPECT) imaging demonstrated contralateral cerebellar diaschisis. We discuss the findings and review the literature concerning contralateral cerebellar diaschisis.

Regional distribution of a creatine transporter in rat auditory brainstem: an in-situ hybridization study

The expression of an mRNA encoding a creatine transporter (CRT1) was investigated in the rat auditory system under ambient sound conditions, using radiolabeled and non-radiolabeled oligonucleotide in-situ hybridization. The results indicated that CRT1 mRNA is widely distributed in auditory nuclei, including the fusiform and deep layers of the dorsal cochlear nucleus, the ventral cochlear nucleus, the superior olivary complex, the nuclei of the lateral lemniscus and the inferior colliculus. The molecular layer of the dorsal cochlear nucleus and the medial geniculate have low levels of label. Creatine provides cells with a reservoir of high-energy phosphate. Neurons do not synthesize creatine but accumulate it by a transport mechanism, which is probably the limiting step in the regulation of intracellular creatine. Therefore, the quantity of transporter expressed may reflect the utilization of creatine and could serve as an in-vitro indicator of endogenous high-energy metabolism in some cells. Although most auditory nuclei express CRT1 mRNA, the quantity of CRT1 mRNA varies among auditory nuclei, indicating that many auditory nuclei have high and fluctuating energy requirements. The level of CRT1 transcript or protein may be regulated by chronic metabolic changes in the auditory system that may occur, for example, with damage to the acoustic organ or the aging process.

Red nuclear and cerebellar but no olivary activation associated with essential tremor: a positron emission tomographic study

There has been debate as to whether essential tremor has a central origin and over the possible role of the inferior olivary nucleus in its genesis. We used positron emission tomography with radioactive water (H2(15)O) to detect abnormal patterns of cerebral activity associated with this condition, at rest, without tremor, and on posture when the tremor was present. At rest, cerebellar blood flow was significantly increased bilaterally in the group with essential tremor (30-40%) but no increased olivary activity was evident. Essential tremor during arm extension was associated with further abnormal increases in bilateral cerebellar and abnormal red nuclear activation. Again, no olivary overactivity was evident. Voluntary wrist oscillation in control subjects caused only ipsilateral cerebellar activation. We conclude that essential tremor is associated with abnormal bilateral overactivity of cerebellar and red nuclear connections but found no evidence of intrinsic overactivity of the inferior olivary nucleus, as evidenced by raised blood flow.

Development of the precerebellar nuclei in the rat: II. The intramural olivary migratory stream and the neurogenetic organization of the inferior olive

Sequential thymidine radiograms from rats labeled on days E13 and E14, and killed at daily intervals thereafter, were analyzed to trace the migratory route and settling pattern of neurons of the inferior olive. Long-survival thymidine radiograms from perinatal rats injected on day E14 were used to subdivide the inferior olivary complex on the basis of neurogentic criteria. The inferior olivary neurons originate on days E13 and E14 in the primary precerebellar neuroepithelium. The olivary neurons labeled on day E14 (the late generated components) translocate into the inferior olivary premigratory zone on day E15. On day E16 these cells join the olivary migratory stream, which follows an intramural circumferential path between the gray and white matters of the medulla. By day E17 the olivary migratory stream is reduced to a small band near the corpus of the inferior olive, which has been settled by this time by neurons generated on day E13. As a result, the unlabeled cells are situated on day E17 dorsomedially and the labeled cells ventrolaterally. The regional segregation of neurons forming subdivisions of the inferior olive begins on day E18, and by day E19 the major subdivisions are all recognizable. In thymidine radiograms from perinatal rats injected on day E14, four neurogenetic components can be distinguished in the inferior olive, those composed: (1) of unlabeled cells (generated on day E13), (2) of predominantly unlabeled cells, (3) of predominantly labeled cells (generated on day E14), and (4) of labeled cells. By combining these neurogenetic differences with the morphological features of the inferior olivary complex, we propose a modification of the currently accepted classification. The four major divisions of the inferior olive are the successively produced posterodorsal olive, anterolateral (principal) olive, posteroventral olive, and anteroventral olive. The location and configuration of these divisions are illustrated in relation to the traditional classification both in the coronal and the sagittal plane.

CT in the evaluation of the vestibulocochlear nerves and their central pathways. Evaluation of neurotologic disorders

CT has evolved to become an important technique for the diagnosis of neurotologic disorders. By obtaining thin sections, the central pathway of the vestibulocochlear nerve can be rather properly evaluated with satisfactory clinical correlation when pathology exists. The validity of central vestibular and audiometric signs can be best substantiated with CT. The functional neuroanatomy of the vestibulocochlear and vestibulo-oculomotor systems is discussed. Results of the assessment of endocranial lesions involving the vestibulocochlear system are presented.

Computed tomography of olivopontocerebellar degeneration

Computed tomographic (CT) studies of 17 cases of olivopontocerebellar degeneration are reported. In all cases, atrophy of brainstem and cerebellum was found. Atrophy of the cerebellar hemispheres was equal to, or more marked than, atrophy of the vermis. Dilatation of lateral ventricles and cerebral sulci was often present. These findings, which are in agreement with the pathologic data, are compared with those reported in other cerebellar atrophic processes. Knowledge of the distribution of the atrophic changes is essential in attempting a differential diagnosis among the degenerative diseases involving the posterior fossa nervous structures.

Computed tomography of the medulla

The medulla was studied in cadavers and in 100 patients both with and without the intrathecal administration of contrast material. The computed tomographic (CT) anatomy was correlated with the appearance of anatomic dissections. The pyramids, olives, and inferior cerebellar peduncles produced characteristic contours on cross sections of the medulla. The hypoglossal nerve by its location and course in the medullary cistern could be distinguished from the glossopharyngeal, vagal, and spinal accessory nerves. For optimal evaluation of the medulla, intrathecal administration of metrizamide and 5- and/or 1.5-mm-thick axial and coronal sections are recommended.

Degenerative disorders of the cerebellum studied by computerized tomography

A review of our cases as well as of the clinical and radiological literature indicates that, in instances of cerebellar degeneration, certain CT patterns are constant. The most reliable are: 1. Prominence of cerebellar sulci. These are usually not seen normally, except for some of the primary fissures; in atrophy the sulci are easily distinguished. 2. Enlargement of the superior cerebellar cistern and vermian cistern. 3. Enlargement of the cerebellopontine cistern. This cistern, which is also referred to as the cerebellopontine angle cistern and as the lateral recess of the cerebellopontine cisterns, is particularly prominent when the middle cerebellar peduncle is significantly involved. 4. Enlargement of the pre-pontine cistern, which occurs primarily with involvement of the pons. 5. The fourth ventricle may be enlarged, particularly in conditions where the midline cerebellar nuclei are affected. However, the enlargement of the fourth alone does not have to be associated with a pathological process. As previously established with pneumoencephalographic studies, the size of the fourth ventricle can be variable (14). Likewise, enlargement of the cisterna magna is not usually associated with any pathological condition of the cerebellum (15).

X-ray controlled implantation of the brain stem

Using X-rays to improve accuracy of stereotaxic implantation of the brain stem of Macaca irus monkeys overcomes the problems of moveable brain stem and inaccurate fixation in the stereotaxic frame. The method is independent of standard atlases and correct ear bar fixation. The key to the method is the establishment of a nomogram which relates the implantation target to bony landmarks. The nomogram is established by X-ray contrast studies which outline the brain stem, the implantation target in the brain stem being decided by superimposed histology. This target is nomographically related to bony landmarks seen both on the contrast X-ray and on a plain X-ray taken later at implantation with the monkey in the stereotaxic frame. Being able to locate the target on this plain X-ray, and having included on the X-ray a metal marker, the stereotaxic coordinates of which are known, the distance can be measured (allowing for X-ray magnification) between target and stereotaxic marker and thus one computes the target coordinates. Accuracy of implantation according to these coordinates is monitored with further plain X-rays.