Snap Shot A two-year-old infant is noted to have paralysis of upward gaze. An image is shown. Introduction Bilateral paralysis of upward gaze as a result of a midbrain tectum lesion commonly a pineal tumor May cause obliteration of the CSF pathways and cause symptoms of an elevated ICP Presentation Symptoms headache nausea vomiting hydrocephalus seizures Physical exam bilateral paralysis of upward gaze Evaluation Neuroimaging