63 year old female in coma status post occipital craniectomy

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Presentation transcript:

63 year old female in coma status post occipital craniectomy Teaching NeuroImages Neurology Resident and Fellow Section © 2015 American Academy of Neurology

Vignette Our patient was a 63 year old female status post occipital craniectomy for cerebellar abscess. She subsequently had decline in her level of consciousness and exhibited ocular roving. There were absent oculocephalic reflexes, intact corneal reflexes and pupillary light reflexes. Patient exhibited bobbing eye movements which increased with noxious stimuli. The patient did not localize or posture when the eye movements were present. Ruff et al © 2015 American Academy of Neurology

Video Slow upward ocular bobbing: slow upward conjugate eye movement followed by return to midposition previously described with pontine lesions and cryptococcal meningitis. MRI Left: T1 sagittal image demonstrating ventral pontine flattening and brain sag and occipital pseudomeningocele. Right: The pseudomeningocele is more prominent with T2 imaging (axial T2). Ruff et al © 2015 American Academy of Neurology

Slow Upward Ocular Bobbing In the comatose patient, eye movements may help localize the level of brainstem damage, or the depth of coma. Absence of cortical control means absence of voluntary saccades including the quick phase of nystagmus and tracking eye movements. Slow-upward ocular bobbing, which our patient exhibited, consists of slow upward bobbing followed by a fast downward return to mid-position Our patient had a complication of undiagnosed CSF leak in the setting of a post surgical pseudomeningocele. Imaging revealed brain sag with ventral pontine flattening (previous slide) and restricted diffusion in the left temporal and parietal lobes (not shown). The patient remained in coma requiring mechanical ventilation and passed shortly after care was withdrawn. 1. Goldschmidt TJ, Wall M. Slow-upward ocular bobbing. J Clin Neuroophthalmol. 1987 Dec;7(4):241-3. PubMed PMID: 2963031. 2. Mehler MF. The clinical spectrum of ocular bobbing and ocular dipping. J Neurol Neurosurg Psychiatry. 1988 May;51(5):725-7. PubMed PMID: 3404172; PubMed Central PMCID: PMC1033087. Ruff et al © 2015 American Academy of Neurology