Horizontal Nystagmus Research Articles

Oculocutaneous Albinism.

A 5-year-old Chinese girl presented intense photophobia and blurring vision from birth. Her uncorrected visual acuity was 20/200 for the right eye and 10/200 for the left eye. The best-corrected visual acuity was 30/200 and 20/200, respectively. Both eyes had horizontal pendular nystagmus. The iris of both eyes was diaphanous translucent. Retinal examination showed a lack of pigment, notably large choroidal vessels, and macular hypoplasia (Fig. 1). Optical coherence tomography results demonstrated an absence of the foveal pit and loss of usual thinning of macula. She also had white eyelashes and hypopigmentation of skin and hair (Supplementary Digital Content, Fig. 1, https://links.lww.com/APJO/A131). Her parents are cousins, and both had neither albinism nor other systematic or ocular diseases. Sunglasses were recommended to relieve the symptom of photophobia. Appropriate sunscreens and periodic inspection for early detection of skin cancer were advised.Figure 1: Color images of anterior segment indicated diaphanous translucent iris. The fundus images showed lack of pigment, notably large choroidal vessels, as well as macular hypoplasia for the retina of the patients.

Possible Brainstem Anaesthesia in a Cat after Ultrasound-Guided Retrobulbar Block

A 13-year-old neutered, blue-eyed female Siamese cat with a bodyweight of 4.8 kg was admitted for enucleation of the right eye. An ultrasound guided retrobulbar block with 1 mL of ropivacaine was performed under general anaesthesia. When the tip of the needle was visualised inside the intraconal space, negative aspiration of the syringe before injection and no obvious resistance during injection were confirmed. Instantly, after ropivacaine was administered, the cat became apnoeic, and its heart rate and the blood pressure increased significantly for a short period of time. During surgery, the cat needed cardiovascular support to maintain blood pressure and was under continuous mechanical ventilation. Spontaneous breathing returned 20 min after the end of anaesthesia. Brainstem anaesthesia was suspected, and after recovery, the contralateral eye was examined. A reduced menace response, horizontal nystagmus, mydriasis, and absence of the pupillary light reflex were present. The following day, mydriasis was still present, but the cat was visual and was discharged. The inadvertent intra-arterial injection of ropivacaine was suspected to be the cause of the spread into the brainstem. To the current authors' knowledge, possible brainstem anaesthesia has only been reported in a cat 5 min after a retrobulbar block but never instantly.

Video head impulse testing in patients with isolated (hemi)nodular infarction.

Isolated (hemi)nodular strokes as underlying cause of acute dizziness are rare, thus there are still gaps of knowledge in the clinical presentation of affected patients. Clinical and experimental evidence has suggested that lesions involving the nodulus lead to various vestibulo-ocular deficits including prolonged velocity-storage, periodic-alternating nystagmus, positional nystagmus, abolished suppression of post-rotatory nystagmus by head-tilt and impaired verticality perception. At the bedside, the angular vestibulo-ocular reflex (aVOR), as assessed by the horizontal head-impulse test (HIT), has been reported to be normal, however quantitative assessments of all six semicircular canals are lacking. The primary aim of this case series was to characterize the spectrum of clinical presentations in isolated (hemi)nodular strokes. Furthermore, based on preliminary observations, we hypothesized that the aVOR is within normal limits in isolated nodular strokes. We retrospectively included patients with isolated (hemi)nodular stroke on diffusion-weighted MR-imaging from a prospective stroke-registry. All patients received a standardized bedside neuro-otological assessment and quantitative, video-based HIT (vHIT) of all six semicircular canals. Overall ratings of vHIT (normal vs. abnormal function) were performed independently by two reviewers and disagreements were resolved. Between January 2015 and December 2021 six patients with isolated nodular (n = 1) or heminodular (n = 5) ischemic stroke were included. Clinical presentation met diagnostic criteria for acute vestibular syndrome (AVS) in 5/6 patients and for episodic vestibular syndrome (EVS) in 1/6 patients. Ocular motor abnormalities observed included the presence of spontaneous horizontal nystagmus (n = 2), positional nystagmus (5/6), head-shaking nystagmus (3/6), skew deviation (n = 1), and moderate or severe truncal ataxia (5/6). Bedside HIT was normal in all patients and no gaze-evoked or periodic alternating nystagmus was observed. aVOR-gains were within normal range in all patients and overall aVOR-function as assessed by vHIT was rated as normal in all six patients. Using quantitative, video-based testing of the horizontal and vertical aVOR, preserved integrity of the aVOR in (hemi)nodular strokes was confirmed, extending preliminary findings at the bedside. Furthermore, widespread deficits of both ocular stability, postural control and volitional eye movements were observed in our study cohort, being consistent with findings reported in previous studies.

The role of vestibular cold caloric tests in the presence of spontaneous nystagmus.

The bithermal caloric test is commonly used to detect a canal paresis. However, in case of spontaneous nystagmus, this procedure can provide results of non-univocal interpretation. On the other hand, confirming the presence of a unilateral vestibular deficit can help to differentiate between central and a peripheral vestibular involvement. We studied 78 patients suffering from acute vertigo and showing spontaneous horizontal unidirectional nystagmus. All patients were submitted to bithermal caloric tests, and the results were compared with those obtained using a monothermal (cold) caloric test. We demonstrate the congruence between the bithermal and monothermal (cold) caloric test through mathematical analysis of the results of both tests in patients with acute vertigo and spontaneous nystagmus. We propose to perform the caloric test in the presence of a spontaneous nystagmus using a monothermal cold assuming that the prevalence of the response to the cold irrigation on the side towards which the nystagmus beats is a sign of the presence of pathological unilateral weakness and therefore more likely peripheral in its origin.

Reversible Neurotoxicity Due To Excessive Use of Ethyl Chloride

BackgroundEthyl chloride is commercially available as a DVD/VCR cleaner, and can be found as a gasoline additive and topical anesthetic. There is an emerging trend of recreational huffing to enhance sexual relations. Neurotoxicity from repeated abuse is uncommon. Case ReportA 36-year-old man with a history of intermittent ethyl chloride use for 15 years presented to the Emergency Department with an inability to walk for 4 days after frequent use for 1 week. The patient reported a rapid titration of inhalation from zero to eight cans of 4.6 oz ethyl chloride aerosol per day over a 1-week period. Initial vital signs were heart rate 88 beats/min, blood pressure 147/60 mm Hg, temperature 37.2°C (99°F), and respiratory rate 16 breaths/min. Physical examination was notable for slurred speech, ptosis, a wide-based and ataxic gait with short strides, inability to stand without support, loss of toe/finger proprioception, horizontal and vertical nystagmus, and dysmetria on coordination testing. Strength and sensation were preserved. His work-up included computed tomography and magnetic resonance imaging of the brain, cervical, thoracic, and lumbar spine that demonstrated no acute abnormalities. On hospital day 9, the patient was able to ambulate with mild difficulty. Why Should an Emergeny Physician Be Aware of This?Toxicity from excessive ethyl chloride huffing has been rarely reported. The toxicity was characterized with cerebellar findings, no attributable laboratory abnormalities, and no radiographic abnormalities on computed tomography/magnetic resonance imaging. The neurotoxicity resolved with supportive care.This case of excessive huffing of ethyl chloride presenting with neurotoxicity and ataxia further characterizes a rare complication of ethyl chloride toxicity that is gaining popularity.

Spontaneous regression of tumor in a girl with optic pathway glioma with diencephalic syndrome.

Spontaneous regression of tumor in a girl with optic pathway glioma with diencephalic syndrome.

Diferencijalna dijagnoza vertiga - prikazi slučajeva

Introduction: Vertigo represents illusion or hallucination of movement caused by disturbance of perception of own movements or movements of observed object. It is caused by dysfunction of the inner ear vestibular apparatus (peripheral vertigo) or parts of central nervous system (central vertigo). Making distinction between these two types is very important for the making of rational decision by emergency medicine physician. Case report I: Female, 69 years of age is referred to neurologist in Emergency Center for attacks of acute onset rotatory vertigo, horizontal nystagmus and severe autonomic disturbances provoked by movement. Anamnesis, clinical, neuroultrasound examinations and CT scan showed no signs of acute neurologic disease. Treatment of peripheral type vertigo with vasodilators was indicated and further continued with otolaryngologist follow up. Case report II: Male, 72 years of age was treated on Clinic of Neurology for infarction of left cerebellar hemisphere. Symptoms at onset were vertigo, headache, diplopia, nausea and vomiting. Neurological examination revealed right sided horizontalrotatory nystagmus with fine vertical nystagmus, astasia/abasia and right sided hemiparesis. Treatment included thrombolytic, antithrombotic and anticoagulant therapy, as well as established vascular risk treatment. Conclusion: Role of emergency physician in establishing of etiology of vertigo at the place of onset is very important. Detailed anamnesis about onset of symptoms and their duration, clinical examination, diagnostic (ABCD2) score, and therapeutic repositioning (Epley) maneuver ensure fast triage and shorter transport delays if necessary.

Effects of phenobarbital, potassium bromide and topiramate on intractable epilepsies in two cases of holoprosencephaly

We describe the courses of treatment for epilepsies in two patients with semilobar type holoprosencephaly (HPE); a 5-year-old girl and a 30-year-old man. Seizure semiology included eye fixation, upward or lateral gaze, horizontal or vertical nystagmus, eyelid flutter, and grinning facial distortion, which frequently evolved to generalized tonic convulsions. In both patients, ictal electroencephalography revealed seizure onset with rhythmic activity in bilateral frontopolar areas. Administration of phenobarbital with subsequent elevation of blood levels to 30–40 μg/ml alleviated the clustered tonic seizures. This allowed dosage reduction of other antiepileptic drugs that had sedative and/or respiratory adverse effects causing significant distress in these patients. Potassium bromide 20–50 mg/kg/day and topiramate 1–3 mg/kg/day were also beneficial in these patients. A combination regimen of these three antiepileptic drugs could be a promising treatment option for intractable epilepsy in HPE.

Intramedullary hemangioblastoma. Case report

Hemangioblastomas are benign tumors that develop from the vessels of the central nervous system and can be a manifestation of autosomal dominant von Hippel-Lindau disease. Statistically, they account for 1.5‒2.5% of all intracranial tumors and 2‒15% of spinal cord tumor lesions. There are very few publications on the intramedullary localization of these neoplasms.The patient, 45 years old, a serviceman, presented with complaints of headache, slight unsteadiness of gait, as well as slight weakness in the right extremities, more pronounced in the right upper extremity, periodic numbness of the upper extremities, which progressed and made further service impossible. On neurological examination: pupils D=S, light reflexes were brisk, eye movement was fully preserved and horizontal nystagmus. BNI - PS - I, BNI - NS - I. HB - I. GR - I. Swallowing and phonation were fully preserved. There was a slight hemiparesis on the right. Hemihypesthesia on the right was more prominent in the upper extremity. Ataxia of mixed genesis. Pelvic organs function was preserved. Periodic constipation for up to 7 days. Magnetic resonance imaging revealed a multifocal brain lesion. Supratentorially, a cystic mass measuring 2.60×2.12×2.14 cm with a solid component up to 1.5 cm in the diameter was detected in the of the thickened corpus callosum. Intramedullary cystic-solid lesion of the medulla oblongata extending to the cervical spinal cord with conventional dimensions of the solid component 1.76×1.23×1.57 cm and the cystic component was 1.52×1.62×1.22 cm. Magnetic resonance imaging of the cervicothoracic region of the spinal cord revealed significant hydromyelitic expansion of the central canal from the C2 level to the Th3 level (up to 10mm in the diameter). Endovascular embolization of the neoplasm with a liquid embolic agent (Phil) and following microsurgical en bloc tumor resection were performed.Hemangioblastomas with an intramedullary location are extremely difficult and risky for the surgical removal. The presence of a cystic component in the hemangioblastoma structure or perifocally gives a chance to remove such a neoplasm avoiding risk of functional deterioration. Preoperative endovascular obliteration of hemangioblastoma vascularity is considered as an effective measure, although it is associated with a risk of cerebral ischemia in corresponding brain structures. Another crucial issues of intramedullary hemangioblastoma surgery includes multimodal intraoperative neuromonitoring and maximum possible intraoperative magnification to minimize injury of adjacent brain structures. Present practice shows that multiple intramedullary cysts in the spinal cord commonly regressing after neoplasm removal and leads to improvement of neurological deficit within a relatively short period of time.Conclusions. Hemangioblastomas with intramedullary growth and perifocal cyst can be surgically removed with a good functional result and comprehensive approach includes preoperative selective angiography with endovascular embolization, multimodal intraoperative neuromonitoring and appropriate microsurgical technique.

Modern vestibular tests can accurately separate stroke and vestibular neuritis.

To separate posterior-circulation stroke (PCS) and vestibular-neuritis (VN) using quantitative vestibular tests. Patients were prospectively recruited from the emergency room within 72h of presentation. Video-nystagmography (VNG), three-dimensional video head-impulse testing (vHIT), vestibular-evoked myogenic potentials (VEMPs), and subjective visual-horizontal (SVH) were performed. There were 128 PCS and 134 VN patients. Common stroke-territories were: posterior-inferior cerebellar artery, basilar-perforators, multi-territory and anterior-inferior cerebellar artery (41.4%, 21.1%, 14.1%, 7.8%). VN included superior, inferior and pan-neuritis (53.3%, 4.2%, and 41.5%). Most VN and stroke patients presented with acute vestibular syndrome (96.6%, 61.7%). In VN, we recorded horizontal (98.5%) or vertical/torsional spontaneous nystagmus (1.5%) and in PCS, absent-nystagmus (53.9%), horizontal (32%) or vertical/torsional (14.1%) nystagmus. The mean slow-phase velocity of horizontal nystagmus was faster in VN than PCS (11.8 ± 7.2 and 5.2 ± 3.0°/s, p < 0.01). Ipsilesional horizontal-canal (HC) vHIT-gain was lower in VN than in stroke (0.47 ± 0.24, 0.92 ± 0.20, p < 0.001). Ipsilesional catch-up saccades occurred earlier, and their amplitude, prevalence, and velocity were greater in VN than PCS (p < 0.01). Ipsilesional SVH deviation > 2.5° occurred more often in VN than in stroke (97.6% and 24.3%, p < 0.01). Abnormal bone-conducted ocular-VEMP asymmetry ratio was more common in VN than PCS (50% and 14.4%, p < 0.01). Using the ten best discriminators (VNG, vHIT, SVH, and oVEMP metrics), VN was separated from PCS with a sensitivity of 92.9% and specificity of 89.8%. Adding VNG and vHIT to the bedside head-impulse-nystagmus-and-test-of-skew (HINTS) test enhanced sensitivity and specificity from 95.3% and 63.4% to 96.5% and 80.6%. Quantitative vestibular testing helps separate stroke from vestibular neuritis and, when used, could improve diagnostic accuracy in the emergency room.

A case report of Wernicke Korsakoff syndrome in a patient with cholangiocellular carcinoma: An underestimated cause of encephalopathy in cancer patients

Wernicke's encephalopathy, a disorder caused by thiamin deficiency, is characterized by a classical triad of encephalopathy, ataxia, and ophthalmoplegia. Although alcoholism is the most common predisposing factor, it can also be associated with nonalcoholic states (hyperemesis gravidarum, intestinal obstruction, bariatric surgery, and others). This work presents a case of nonalcoholic Wernicke-Korsakoff syndrome diagnosed in a cholangiocellular carcinoma patient and literature review. A 65-year-old male patient with a history of cholangiocellular carcinoma (Klatskin tumor) was treated with radiotherapy at the operation site after Roux-en-Y hepaticojejunostomy. During follow-up, the patient developed gastric outlet obstruction and was diagnosed with peritoneal carcinomatosis after a palliative gastrojejunostomy. As the patient could not tolerate oral nutrition during hospitalization, total parenteral nutrition was administered. After 10 days of admission, the patient showed decreased response to verbal stimuli as well as bilateral horizontal nystagmus, lethargy, and disorientation. Furthermore, the patient displayed confabulation. Clinical and imaging findings were consistent with Wernicke's encephalopathy. Therefore, treatment with intravenous thiamin replacement was initiated. The patient's encephalopathy regressed on the second day after treatment, and he recovered the place-person-time orientation. In the following month, the abnormal imaging findings were almost entirely resolved. In order to prevent irreversible brain damage induced by chronic thiamin deficiency, thiamin replacement therapy with parenteral nutrition solutions should be included as a treatment for hospitalized cancer patients unable to receive enteral nutrition for a long time.

Reliability of Monothermal Caloric Test as Screening Test of Vestibular System

This retrospective study completed at a tertiary care center aimed to assess the monothermal caloric test (MCT) as a screening test, using the bithermal caloric test (BCT) as a reference. Additionally, it attempts to measure the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a fixed inter-auricular difference (IAD) value for both cold and warm stimuli using water irrigation. Medical records of 259 patients referred for vestibular symptoms who underwent BCT with water irrigation were reviewed. Patients with bilateral vestibular weakness and caloric tests using air irrigation were excluded. BCT showed 40.9% unilateral weakness. Two formulas were used to determine the monothermal caloric asymmetry (MCA-1 and MCA-2). The measurement of agreement Kappa between the two formulas in comparison with BCT revealed moderate agreement at 0.54 and 0.53 for hot and cold stimulation, respectively. The monothermal warm stimulating test (MWST) using MCA-2 showed better results, with a sensitivity of 80%, specificity of 91%, PPV of 83.1%, and NPV of 89.2%. Thirty-four patients had horizontal spontaneous nystagmus (HSN) with a mean velocity of 2.25°/s. These patients showed better sensitivity but lower specificity after adjustment of HSN using the MCA-2 formula at warm temperatures. Therefore, they should complete the caloric test with cold irrigation to perform the BCT. MCT is efficient as a screening test if the warm stimulus is used with the MCA-2 formula fixed at 25%. If present, HSNs should be adjusted. Negative IAD (normal) in the absence or presence of adjusted HSN or slow-phase eye velocity ≤ 6°/s at each right and left warm stimulation should be accomplished by the BCT.

NCMP-10. NEURO-OPHTHALMOLOGICAL FINDINGS IN CHILDREN AND ADOLESCENTS WITH MEDULLOBLASTOMA - A RETROSPECTIVE ANALYSIS

Abstract BACKGROUND Medulloblastoma represents the most common malignant pediatric brain tumor. Ophthalmic complications are possible sequelae. METHODS Pediatric medulloblastoma (MB) patients treated at the Medical University of Vienna from January 2012 to August 2021 were analyzed and their last ophthalmic assessment was reviewed. RESULTS Fifty-six MB patients could be included (71.4% non-WNT/non-SHH, 16.1% SHH-activated, 8.9% WNT-activated, 3.6% non-specified). Mean age at diagnosis was 7.2 years (range 0-19). Median follow-up to last ophthalmological assessment was 19.7 months (range 0.1-93.2). Thirty-four children underwent tumor resection at our hospital, their tumor localizations were: vermis (55.9%), floor of the 4th ventricle (26.5%), cerebellar hemispheres (11.8%), lateral recess (5.9%). Symptoms at presentation were evaluable for 51 children: 92.2% had symptoms of elevated intracranial pressure, 76.5% ataxia and 21.6% visual disturbances. Postoperative posterior fossa syndrome was observed in 11.1% of 54 children. 98.2% had chemotherapy as part of their initial treatment and all children older than four years (85.7%) received postoperative irradiation of the posterior fossa. In 13 (23.2%) intraventricular chemotherapy was applied. At the last follow-up 21 patients experienced relapse after primary treatment. At the final assessment, frequent neuro-ophthalmological abnormalities included: oculomotor disturbance (75%), esotropia (35.7%) including abducens palsy (12.5%), other cranial nerve palsies (21.4%), horizontal gaze-evoked nystagmus (51.8%), spontaneous nystagmus (16.1%), ocular tilt reaction (21.4%), and optic disc abnormalities (14.3%). Good visual acuity (≥20/25) was maintained in 62.5% patients. Visual field and optical coherence tomography was successfully performed in 75% and 66.1% of patients, respectively. Optic pathway lesions were detected in 4 patients (7.1%), including two cases with occipital metastases, one with optic nerve metastasis and one with leptomeningeal carcinomatosis. Orthoptic treatment with prisms and strabismus surgery was required in 14.3% and 7.7% of children, respectively. CONCLUSION Children with MB frequently suffer from neuro-ophthalmological late-effects. Regular monitoring is warranted to initiate appropriate management.

A RARE CASE OF WERNICKE'S ENCEPHALOPATHY INDUCED BY HYPEREMESIS GRAVIDARUM: A DIAGNOSTIC DILEMMA

A RARE CASE OF WERNICKE'S ENCEPHALOPATHY INDUCED BY HYPEREMESIS GRAVIDARUM: A DIAGNOSTIC DILEMMA

Ocular symptoms in cerebellitis caused by COVID-19 : Cerebellitis, aless noticed disease with neuro-ophthalmological findings

Das Krankheitsbild der akuten Cerebellitis wurde in den letzten Jahren zunehmend beachtet. Zwei unterschiedliche Verläufe wurden beobachtet: Eine milde Verlaufsform mit leichten ataktischen Störungen (als postinfektiöse, selbstlimitierende Krankheit) und eine fulminante Verlaufsform der Cerebellitis, bei der das vergrößerte Kleinhirn den Aquaeductus Sylvii komprimiert und zu einer intrakraniellen Drucksteigerung mit einem obstruktiven Hydrozephalus und zu einer Hernienbildung der Kleinhirntonsillen im Foramen magnum führt. Dabei kann der Verlauf bei zu späten neurochirurgischen Sofortmaßnahmen letal sein. Eine Cerebellitis wurde als Folge einer Virusinfektion und durch autoimmun hervorgerufene Entzündungen beobachtet. Zahlreiche Mitteilungen befassten sich mit einer Cerebellitis bei Kindern, seltener bei Erwachsenen. An neuroophthalmologischen Befunden wurden häufig Nystagmus (horizontaler Blickrichtungsnystagmus, Vertikalnystagmus, „Down-beat“-Nystagmus, periodisch alternierender Nystagmus), Stauungspapillen, seltener Abduzens- oder Fazialisparese, Photophobie, sehr selten ein Opsoklonus-Myoklonus-Syndrom beschrieben. Wiederholt wurde eine Cerebellitis mit neuroophthalmologischen Befunden während der COVID-19-Pandemie bei Erwachsenen mitgeteilt.

Positive horizontal-canal head impulse test is not a benign sign for acute vestibular syndrome with hearing loss.

BackgroundDiagnosis of acute vestibular syndrome (AVS) with hearing loss is challenging because the leading vascular cause—AICA territory stroke—can appear benign on head impulse testing. We evaluated the diagnostic utility of various bedside oculomotor tests to discriminate imaging-positive and imaging-negative cases of AVS plus hearing loss.MethodWe reviewed 13 consecutive inpatients with AVS and acute unilateral hearing loss. We compared neurologic findings, bedside and video head impulse testing (bHIT, vHIT), and other vestibular signs (including nystagmus, skew deviation, and positional testing) between MRI+ and MRI– cases.ResultsFive of thirteen patients had a lateral pontine lesion (i.e., MRI+); eight did not (i.e., MRI–). Horizontal-canal head impulse test showed ipsilateral vestibular loss in all five MRI+ patients but only in three MRI– patients. The ipsilesional VOR gains of horizontal-canal vHIT were significantly lower in the MRI+ than the MRI– group (0.56 ± 0.11 vs. 0.87 ± 0.24, p = 0.03). All 5 MRI+ patients had horizontal spontaneous nystagmus beating away from the lesion (5/5). One patient (1/5) had direction-changing nystagmus with gaze. Two had skew deviation (2/5). Among the 8 MRI– patients, one (1/8) presented as unilateral vestibulopathy, four (4/8) had positional nystagmus and three (3/8) had isolated posterior canal hypofunction.ConclusionThe horizontal-canal head impulse test poorly discriminates central and peripheral lesions when hearing loss accompanies AVS. Paradoxically, a lateral pontine lesion usually mimics unilateral peripheral vestibulopathy. By contrast, patients with peripheral lesions usually present with positional nystagmus or isolated posterior canal impairment, risking misdiagnosis as central vestibulopathy.

Bilateral papilledema with vision loss due to post–COVID-19–induced thiamine deficiency: illustrative case

BACKGROUNDBilateral papilledema with vision loss is considered a neurosurgical emergency due to high intracranial pressure. However, it may not be the only cause of papilledema. The authors reported an association among coronavirus disease 2019 (COVID-19), bilateral papilledema, blindness, and Wernicke’s encephalopathy (WE).OBSERVATIONSAn 18-year-old woman presented to the neurosurgery service with rapid profound vision loss and bilateral papilledema. She had COVID-19 3 months earlier with subsequent loss of smell (anosmia) and taste (ageusia), which resulted in hyperemesis and a 43-lb weight loss. Examination revealed ataxia, horizontal nystagmus, and blindness. Magnetic resonance imaging and magnetic resonance venography of her brain were normal. Presumptive diagnosis of WE was made, and she was treated with intravenous thiamine with restoration of vision within 48 hours. Patient’s thiamine level was less than half the normal value.LESSONSNeurosurgeons should be aware of this unique correlation between papilledema and vision loss and its association with WE due to post–COVID-19 hyperemesis and weight loss from anosmia and ageusia.

Acute Cognitive Dysfunction in a Patient With Traumatic Brain Injury: A Clinical Vignette.

Acute Cognitive Dysfunction in a Patient With Traumatic Brain Injury: A Clinical Vignette.

Teaching Video NeuroImage: Subacute Cerebellar Ataxia in an Adolescent With Antibodies Against Metabotropic Glutamate Receptor Type 1.

A 15-year-old boy developed progressive cerebellar dysfunction over 3 weeks. Examination showed ataxic gait, unsteady tandem gait, horizontal nystagmus, intention tremor, and ataxia on heel-toe-shin testing (Video 1, [links.lww.com/WNL/C323][1]). Dysdiadochokinesia and dysarthria were found but not illustrated in the video. Neuroimaging and CSF biochemistry was normal. Serum and CSF metabotropic glutamate receptor type 1 (anti-mGluR1) autoantibodies were found. His cerebellar function improved markedly within 3 months of initiating immunotherapy (Video 1, [links.lww.com/WNL/C323][1]). The median age at onset of anti-mGluR1 encephalitis is 55 years.1,2 Paraneoplastic syndromes should be considered, but anti-mGluR1 encephalitis is more often autoimmune in younger patients.1,2 [1]: http://links.lww.com/WNL/C323

Republication de : Central nystagmus and alterations in vestibular tests due to an inadvertent gentamicin administration into spinal space: A CARE case report

Gentamicin has a well-known potential for damaging the peripheral vestibular organs. However, it is considered to be innocuous to the CNS as it crosses the blood-brain barrier poorly. Here, we describe central neuro-otological abnormalities developed by a patient after deployment of gentamicin into his spinal space. A 61-year-old male unintentionally received gentamicin during spinal locoregional anesthesia for a urological procedure. During the first 48 hours the patient presented upper extremity dysmetria, dysarthria, and bilateral abducens nerve paralysis from which he recovered completely. He remained asymptomatic from day 3 to 10 after the incident. On day 11 he presented an acute vestibular syndrome. Severe bilateral vestibulopathy was confirmed by means of video head impulse testing. From day 14 onwards, he presented a persistent horizontal left-beating nystagmus, showing no variation or signs of compensation after 14 months, not responding to intensive vestibular rehabilitation or vestibular suppressant drugs. During follow-up, intercurrent gaze-evoked/direction-changing nystagmus has been recorded in various opportunities. We interpreted these findings as signs of both severe peripheral bilateral vestibulopathy and cerebellar and/or midbrain late-onset neurotoxicity, which can be explained by the intrinsic neurotoxic capability of high doses of gentamicin in the CNS.