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PSP – Supranuclear vs Nuclear Gaze Palsy — SCE Neurology MCQ

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ModerateMovement DisordersPSP – Supranuclear vs Nuclear Gaze PalsySCE Neurology

A 65-year-old woman presents with progressive difficulty initiating gait, frequent freezing episodes, and falls over 2 years. She has no tremor and minimal limb rigidity. Examination shows axial rigidity, retrocollis (neck extension), and a characteristic 'staring' facial expression with reduced blink rate. Vertical saccades are markedly slow but full-range vertical gaze is maintained with the oculocephalic (doll's eye) manoeuvre. What does this finding indicate?

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Correct answer: C — Supranuclear gaze palsy — the gaze palsy is above the level of the cranial nerve nuclei

In progressive supranuclear palsy, the vertical gaze palsy is supranuclear — meaning the deficit is in the cortical/subcortical pathways commanding voluntary saccades, while the brainstem nuclei and fascicles are intact. This is demonstrated by the intact oculocephalic reflex (doll's eye manoeuvre) which bypasses the supranuclear pathways and directly stimulates the vestibulo-ocular reflex via the brainstem. A: A nuclear palsy would not be overcome by the doll's eye manoeuvre. C: INO involves the MLF. D: Myasthenic fatigue shows variability. E: Functional disorders show inconsistency.

Reference: MDS PSP Diagnostic Criteria (2017)