Selective saccadic palsy after cardiac surgery

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Identifier Schnure-Saccade-Video
Title Selective saccadic palsy after cardiac surgery
Subject Saccade, saccadic palsy, cardiac surgery
Creator Nilan D. Schnure, MD, Resident Physician, Internal Medicine; Ali G. Hamedani, MD, MHS, Resident Physician, Department of Neurology; Grant T. Liu, MD, Chief, Division of Neuro-Ophthalmology; Hospital of the University of Pennsylvania
Description A unique gaze palsy selectively affecting saccades while sparing smooth pursuit, vergence, and vestibular reflex eye movements has been described following uncomplicated cardiac (and especially ascending aortic) surgery . This 69 year-old man reported persistent visual complaints immediately after a type A aortic dissection repair twelve years ago. He was previously in good health with no known neurologic deficits but after developing chest pain and transient lower extremity paraparesis was found to have acute aortic dissection. He underwent ascending aorta replacement with subsequent RCA bypass graft for right ventricular failure, after which he developed difficulties with eye movement, speech, and swallowing. These deficits were initially attributed to a perioperative ischemic stroke but multiple MRIs showed no evidence of brainstem ischemia. This presentation is typical of a syndrome characterized by severe saccadic slowing and hypometria with spared smooth pursuit, vergence, and vestibulo-ocular reflex eye movements that occurs following ascending aortic and cardiac surgery . Similar to other cases, this patient also developed dysarthria, ataxia, and postural instability resembling progressive supranuclear palsy (PSP); he also developed localization-related epilepsy two years after his initial presentation. Given the sudden onset of isolated ocular motor deficits in the absence of imaging abnormalities, this selective saccadic palsy after cardiac surgery is unlikely to be due to perioperative thromboembolic events, diffuse cerebral hypoxia, or exacerbation of an unrecognized PSP-like neurodegenerative disorder. Rather, autopsy studies of similar patients suggest that selective injury to saccade-generating excitatory burst neurons and omnipause neurons (which are among the most highly metabolically active neurons in the body) or their extracellular support structures (also known as perineuronal nets) in the brainstem may be responsible for this phenomenon . In this video, we demonstrate the stable ocular motor deficits present in this patient twelve years after symptom onset. Video Description: First, the patient is asked to look left, right, up, and down but is unable to generate voluntary saccades. Next, he is asked to maintain fixation during passive head movement, demonstrating intact vestibulo-ocular reflexes. Finally, smooth pursuit is tested in all directions and is largely preserved except in upgaze.
References 1. Mokri B, Ahlskog E, Fulgham J, and Matsumoto, J. Syndrome resembling PSP after surgical repair of ascending aorta dissection or aneurysm. Neurology 2004; 62: 971-973. 2. Solomon D, Ramat S, Tomsak R, et al. Saccadic palsy after cardiac surgery: characteristics and pathogenesis. Annals of Neurology 2008; 63: 355-365. 3. Eggers S, Horn A, Roeber S, et al. Saccadic palsy following cardiac surgery: a review and new hypothesis. Ann N Y Acad Sci 2015; 1343(1): 113-119.
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 2017-07-09
Format video/mp4
Rights Management Copyright 2017. For further information regarding the rights to this collection, please visit:
Holding Institution North American Neuro-Ophthalmology Association. NANOS Executive Office 5841 Cedar Lake Road, Suite 204, Minneapolis, MN 55416
Collection Neuro-ophthalmology Virtual Education Library: NOVEL
File Name Schnure-Saccade-Video.mp4
Language eng
ARK ark:/87278/s63814bq
Setname ehsl_novel_novel
Date Created 2017-10-09
Date Modified 2021-05-06
ID 1277496
Reference URL
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