Research in Vestibular Science

Fourth Nerve Paresis plus Crossed Horner Syndrome in Acute Leukemia: Sumin Kim, Sung-Hee Kim; Res Vestib Sci. 2022;21(3):86-88. Published online September 15, 2022; DOI: https://doi.org/10.21790/rvs.2022.21.3.86

Abstract PDF: A 29-year-old patient with diplopia showed a unilateral fourth nerve palsy combined with a Horner syndrome on the opposite side. Magnetic resonance images disclosed a focal hemorrhage in the left dorsal midbrain, affecting the nucleus of the fourth nerve and adjacent oculosympathetic fibers. Further evaluations including a bone marrow biopsy confirmed acute lymphoblastic leukemia. The combination of ocular motor and oculosympathetic palsy has a distinct localizing value. Fourth nerve palsy ipsilateral to Horner syndrome locates lesion in the cavernous sinus, while contralateral fourth nerve palsy locates the lesion in the midbrain.

Tullio Phenomenon Following Spontaneous Intralabyrinthine Gross Hemorrhage: Jae Won Choi, Jong Jun Kim, Young Hyo Kim, Hyun Woo Lim; Res Vestib Sci. 2013;12(4):140-144.

Abstract: Tullio phenomenon is a pattern of sound induced unsteadiness, imbalance or vertigo, associated with disturbances of oculomotor and postural control. As a possible cause of sudden sensorineural hearing loss, intralabyrinthine gross hemorrhage has been reported in subjects with bleeding tendency. We report a case of spontaneous intralabyrinthine hemorrhage followed by presentation of Tullio phenomenon. A 35-year-old man presented with sudden left side hearing loss and vertigo. Audiometry results indicated left total deafness and magnetic resonance images revealed left intralabyrinthine hemorrhage. At 1 month after hearing loss, sound and pressure-induced vertigo and disequilibrium newly developed. Follow-up images indicated signs of fibrosis in the left labyrinth and nystagmography results showed induction of nystagmus according to the stapedial reflex. This case suggests possibility of Tullio phenomenon in sudden sensorineural hearing loss patients.

A Case of Lateral Medullary Syndrome with Ipsilesional Nystagmus due to Intramedullary Hemorrhage: Ki Bum Sung, Ji Yun Park, Sun Ah Park, Tae Kyeong Lee; Res Vestib Sci. 2009;8(1):52-55.

Abstract PDF: We report a rare case of primary dorsal medullary hemorrhage showing lateral medullary syndrome with ipsilesional nystagmus. A 41-year woman, presented with the first degree horizontal vestibular nystagmus and ocular tilt reaction to the left in lateral medullary hemorrhagic lesion. Primary medullary hemorrhage is rare and details of the abnormal eye movement in the lesion have never been described well. While most of the reported vestibular nystagmus in the lateral medullary infarction was contralesional., the nystagmus in this case was ipsilesional. This ipsilesional beating of the nystagmus might be explained that either destruction of the rostral part of vestibular nuclei or irritative effect of blood to vestibular nuclei is responsible. In addition, ocular tilt reaction (OTR) can be more important in deciding the side of the lesion in medullary hemorrhage. Key Words: Lateral medullary syndrome; Medulla oblongata, Hemorrhage; Nystagmus, Pathologic

Bilateral Internuclear Ophthalmoplegia Following Spontaneous Subarachnoid Hemorrhage: Se Jin Oh, Kwang Dong Choi, Dae Soo Jung; J Korean Bal Soc. 2008;7(2):204-206.

Abstract PDF: A 44-year-old woman presented with horizontal diplopia 2 days after spontaneous subarachnoid hemorrhage. Neurological examination disclosed bilateral internuclear ophthalmoplegia and neck stiffness. Neurovascular imagings documented subarachnoid and intraventriclar hemorrhage with an aneurysm arising from the left superior cerebellar artery, and vasogenic edema in the bilateral pontomesencephalic junction. Parenchymal vasogenic edema due to microvascular damage may give rise to bilateral internuclear ophthalmoplegia during the acute stage of spontaneous subarachnoid hemorrhage. Key words: Bilateral internuclear ophthalmoplegia, Spontaneous subarachnoid hemorrhage, Vasogenic edema

Tonic inward and downward deviation of the eye: Kwang Dong Choi, Dae Soo Jung, Ji Soo Kim; J Korean Bal Soc. 2003;2(1):133-137.

Abstract PDF: Background
Tonic inward and downward deviation of the eyes ('peering at the tip of the nose') is regarded as a unique feature of thalamic hemorrhage, but the mechanisms of this ocular finding remain obscure. Objective: To report on four patients who showed tonic inward and downward deviations of the eyes from either brainstem or thalamic lesions, and to discuss the possible mechanisms involved. Design: Case report Setting: Secondary and tertiary referral hospitals
Results
One patient developed alternating esotropia with downward ocular deviation from thalamic hemorrhage compressing the midbrain. Two patients showed multiple infarctions in the territory of the posterior circulation with or without the involvement of the thalamus. Another patient had lateral pontine hemorrhage extending up to the midbrain tegmentum. Ocular bobbing preceded or accompanied tonic ocular deviation in three patients.
Conclusion
Tonic inward and downward deviation of the eye may develop in thalamic or brainstem lesions. Irritation or destruction of the neural structures involved in the vergence and vertical gaze may cause this ocular sign in mesodiencephalic lesions. Skew deviation and esotropia from abduction deficit may be involved in some patients. Ocular bobbing and tonic downward deviation may share a common pathophysiology.

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