Oculopalatal Tremor and Internuclear Ophthalmoplegia Due to Hemorrhagic Pontine Cavernoma

𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 60-year-old woman who experienced 2 episodes of vertigo, nausea and vomiting, which was felt to be related to recurrent hemorrhage of a pontine cavernoma that was adjacent to the fourth ventricle. The cavernoma was resected, and diplopia and left facial palsy were noted after the surgery. About 6 months later, balance worsened and oscillopsia was experienced for the first time. At the time that this video was taken, more than 12 months had passed since the surgery. Deficits included left lower motor neuron (LMN) facial palsy (damage to the left fascicle of CN7), left internuclear ophthalmoplegia (INO -damage to the left medial longitudinal fasciculus), in addition to vertical-torsional pendular nystagmus and palatal tremor, consistent with oculopalatal tremor. Review of a recently obtained MRI showed bilateral hyperintensity of the inferior olives (IO) on MRI T2/FLAIR sequences due to hypertropic olivary degeneration (HOD). In her case, HOD was related to injury of the descending central tegmental tract (CTT) as it passed through the pons, thereby removing normal inhibition of the IO by the CTT (https://collections.lib.utah.edu/details?id=1278831). 𝗡𝗲𝘂𝗿𝗼-𝗼𝗽𝗵𝘁𝗵𝗮𝗹𝗺𝗼𝗹𝗼𝗴𝘆 𝗮𝗻𝗱 𝗡𝗲𝘂𝗿𝗼-𝗼𝘁𝗼𝗹𝗼𝗴𝘆 𝗧𝗲𝘅𝘁𝗯𝗼𝗼𝗸 𝗟𝗲𝗴𝗲𝗻𝗱: This is a 60-year-old woman who experienced 2 episodes of vertigo, nausea and vomiting, which was felt to be related to recurrent hemorrhage of a pontine cavernoma that was adjacent to the fourth ventricle. The cavernoma was resected, and diplopia and left facial palsy were noted after the surgery. About 6 months later, balance worsened and oscillopsia was experienced for the first time. At the time that this video was taken, more than 12 months had passed since the surgery. Deficits included left lower motor neuron (LMN) facial palsy (damage to the left fascicle of CN7), left INO (damage to the left medial longitudinal fasciculus), in addition to vertical-torsional pendular nystagmus and palatal tremor, consistent with oculopalatal tremor. Review of a recently obtained MRI showed bilateral hyperintensity of the inferior olives (IO) on MRI T2/FLAIR sequences due to hypertropic olivary degeneration (HOD). In her case, HOD was related to injury of the descending central tegmental tract (CTT) as it passed through the pons, thereby removing normal inhibition of the IO by the CTT. (Video and legend created with the assistance of Dr. Tony Brune) https://collections.lib.utah.edu/ark:/87278/s618790z