Pontine Hemorrhage Causing Oculopalatal Tremor and Multiple Cranial Neuropathies

This is a 45-yo-woman who had a dorsal pontine cavernoma that bled 2 years prior to this video. Symptoms included diplopia and oscillopsia. On examination, she had left>right facial palsies (upper and lower face from involvement of the nucleus/fascicle - i.e., lower motor neuron palsies) and sixth nerve palsies (large angle esotropia is apparent in the video). There was no INO and no horizontal gaze palsy on this examination. Regarding the facial palsies, she had developed synkinesis, or aberrant regeneration involving areas around the left lip and right side of the nose - e.g., with blinking, areas of the lower face contracted, which is the result of nerves getting misrouted to the wrong muscles after injury. Additionally, given the close proximity of the central tegmental tract in the dorsal pons, she developed oculopalatal tremor as a result of a disruption in Mollaret's triangle. Nystagmus was pendular vertical-torsional, and palatal tremor was also present. Gabapentin was not tolerated, and memantine did not improve her oscillopsia.