Progressive supranuclear palsy (PSP) or Steele-Richardson-Olszewski syndrome is characterized by a progressive supranuclear ophthalmoplegia typically vertical but in particular downward limitation of eye movement. There is a loss of the voluntary aspect of eye movements, but, as the brainstem is still intact, all the reflex conjugate eye movements are normal. (See also Overview of Neuro-ophthalmologic and Cranial Nerve Disorders .) Parinaud syndrome, also known as the dorsal midbrain syndrome, is a supranuclear vertical gaze disturbance caused by compression of the superior tectal plate. Vertical gaze palsy for either upward or downward gaze is rarely present at symptom onset (8%), usually takes 3–4 years to develop, and precedes the development of horizontal gaze palsy. A conjugate gaze palsy is inability to move both eyes together in a single horizontal (most commonly) or vertical direction. A supranuclear gaze palsy is an inability to look in a vertical direction as a result of cerebral impairment. Downward gaze palsy is usually pathologic and may be seen in brainstem lesions and certain neurodegenerative disorders such as progressive supranuclear palsy or adult Niemanns-Pick disease. Usually, upward gaze is affected. Vertical supranuclear gaze palsy (VSGP) is a key clinical feature in patients with Niemann-Pick type C disease (NP-C), a rare, autosomal recessive, neuro-visceral disorder caused by mutations in either the NPC1 or NPC2 gene. It usually occurs bilaterally; however, it is occasionally seen unilaterally (Rubin 2014). To our knowledge, only one previous case has been reported of a patient with an acute vertical gaze palsy and an isolated thalamic infarction on MRI. PSP Richardson’s syndrome, the most frequent form of the disease, is characterized by vertical supranuclear gaze palsy and postural instability … 2016 2017 2018 2019 2020 2021 Billable/Specific Code. 6 In this case, however, the rostral midbrain (the level of … [1] PSP is recognized as a tauopathy, with a middle age … VSGP is present in approximately 65 % of the cases and is, with gelastic ca … The most common cause of vertical gaze palsy is damage to the top part of the brain stem (midbrain), usually by a stroke or tumor. Vertical gaze palsy Vertical gaze decreases gradually with age, but vertical gaze palsy is more severe than age-related changes. There is often associated loss of balance due to degeneration of neurons in the brainstem and basal ganglia. The authors attributed the vertical gaze palsy to the mesencephalic lesions. This vertical palsy is supranuclear, so doll's head maneuver should elevate the eyes, but eventually all upward gaze mechanisms fail. 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