36-year-old woman with persistent spinning vertigo, diplopia

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Presentation transcript:

36-year-old woman with persistent spinning vertigo, diplopia and blurred vision Teaching NeuroImages Neurology Resident and Fellow Section © 2016 American Academy of Neurology

Vignette permanent persistent spinning vertigo, diplopia and blurred vision acute onset 6 months ago neurological examination revealed uncertain tandem gait no significant past medical history Feil et al. © 2016 American Academy of Neurology

Video The neuro-opthalmological examination revealed jerky and irregular eye movements in the horizontal and vertical direction, i.e., partially diagonal, with a high amplitude of 20-30° in the primary position as well as in lateral gaze. The eye movements continue throughout the examination, they are not induced by gaze shift. Feil et al. © 2016 American Academy of Neurology

Imaging Recording of eye movements by video-oculography (left eye). The patient was asked to fixate a target point. A Traces show horizontal eye position in blue and vertical eye position in red. Upward blue upward traces indicate eye movement to the right, downward to the left (each more than 20°). Since there were also vertical components (documented in red traces), the direction of eye movements was often oblique. B Traces show horizontal eye position. After distraction of the patient (marked by arrow) the irregular eye jerks with inconsistent amplitudes and intersaccadic intervals disappear. Feil et al. © 2016 American Academy of Neurology

Functional saccadic oculomotor disturbances the patient’s eye movements depended on attention video-oculography objectively confirmed this with special findings (high-amplitude, preserved intersaccadic intervals) differences to central oculomotor disturbances: macro square-wave jerks: mostly asymptomatic, paired, small, saccadic intrusions taking the eye off-target, amplitude of 5-15°, intersaccadic interval of 70-150 ms. in opsoclonus, saccadic oscillations occur unpredictably in all directions (horizontal, vertical and diagonal) without an intersaccadic interval References: 1. Kaski D, Bronstein AM, Edwards MJ, Stone J. Cranial functional (psychogenic) movement disorders. Lancet Neurol 2015;14:1196-1205. 2. Leigh RJ, Zee DS, ed. The Neurology of Eye Movements, 5th ed. Oxford, New York2015. Feil et al. © 2016 American Academy of Neurology