Mild Bilateral Internuclear Ophthalmoplegia: The Diagnostic Role of the Vertical Posterior Canal Vestibulo-Ocular Reflex in Acute Brainstem Demyelination, a Clinical-Radiologic Correlation.
Journal
Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society
ISSN: 1536-5166
Titre abrégé: J Neuroophthalmol
Pays: United States
ID NLM: 9431308
Informations de publication
Date de publication:
01 03 2022
01 03 2022
Historique:
pubmed:
19
5
2021
medline:
6
5
2022
entrez:
18
5
2021
Statut:
ppublish
Résumé
The ocular signs of internuclear ophthalmoplegia (INO) with slow, restricted adduction of one eye and abduction nystagmus of the contralateral eye are easily recognized and have a high localizing/lateralizing value. However, subtle INO is difficult to diagnose. Recent reports identified novel vestibular abnormalities in unilateral and bilateral INO. Frequent findings include decreased horizontal and posterior canal gains, and generally relative sparing of both anterior canals. We studied one patient with a subtle bilateral INO, performed serial quantitative saccade (QS) and video head impulse test (vHIT), and correlated clinical-radiological findings caused by acute demyelination. Single case study of a 30-year-old man presented with 1 week of painless, binocular, horizontal diplopia in left gaze. We performed 3 serial neurological examination, QS, vHIT, and clinical-MRI correlation (1 pretreatment and 2 post steroid treatment). We found bilateral slow adducting, clinically positive posterior canal HITs, and borderline abducting saccade velocity, without abducting nystagmus. The videonystagmography with fixation block showed bilateral horizontal gaze evoked nystagmus, and vHIT testing confirmed decreased right horizontal and bilateral posterior canal gains. The abnormalities resolved after steroid treatment. MRI showed acute bilateral medial longitudinal fascicle demyelinating lesions. A bilaterally positive, posterior, canal HIT and slow adduction saccades are localizing findings in bilateral INO, even in the absence of abduction nystagmus. Quantitative confirmation of these findings suggest most frequently an ischemic or demyelinating disorder and are a compelling indication for MRI. This case shows value to testing multiaxial head impulses and performing QS and vHIT in brainstem lesions.
Sections du résumé
BACKGROUND
The ocular signs of internuclear ophthalmoplegia (INO) with slow, restricted adduction of one eye and abduction nystagmus of the contralateral eye are easily recognized and have a high localizing/lateralizing value. However, subtle INO is difficult to diagnose. Recent reports identified novel vestibular abnormalities in unilateral and bilateral INO. Frequent findings include decreased horizontal and posterior canal gains, and generally relative sparing of both anterior canals. We studied one patient with a subtle bilateral INO, performed serial quantitative saccade (QS) and video head impulse test (vHIT), and correlated clinical-radiological findings caused by acute demyelination.
METHODS
Single case study of a 30-year-old man presented with 1 week of painless, binocular, horizontal diplopia in left gaze. We performed 3 serial neurological examination, QS, vHIT, and clinical-MRI correlation (1 pretreatment and 2 post steroid treatment).
RESULTS
We found bilateral slow adducting, clinically positive posterior canal HITs, and borderline abducting saccade velocity, without abducting nystagmus. The videonystagmography with fixation block showed bilateral horizontal gaze evoked nystagmus, and vHIT testing confirmed decreased right horizontal and bilateral posterior canal gains. The abnormalities resolved after steroid treatment. MRI showed acute bilateral medial longitudinal fascicle demyelinating lesions.
CONCLUSIONS
A bilaterally positive, posterior, canal HIT and slow adduction saccades are localizing findings in bilateral INO, even in the absence of abduction nystagmus. Quantitative confirmation of these findings suggest most frequently an ischemic or demyelinating disorder and are a compelling indication for MRI. This case shows value to testing multiaxial head impulses and performing QS and vHIT in brainstem lesions.
Identifiants
pubmed: 34001732
doi: 10.1097/WNO.0000000000001262
pii: 00041327-202203000-00061
doi:
Types de publication
Case Reports
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e281-e288Informations de copyright
Copyright © 2021 by North American Neuro-Ophthalmology Society.
Déclaration de conflit d'intérêts
The authors report no conflicts of interest.
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