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Show IOl/mal of Clillical Nel/ro-t'I"lfhalmol"sy 713':165-166. 1987. Traumatic Internuclear Ophthalmoplegia James R. Keane, M.D. ~ 1'187 Raven Pre". ltd., New y,'rk Unilateral and bilateral internuclear ophthalmoplegia can rarely be caused by trauma. This article illustrates a traumatic pontine hemorrhage associated with bilateral internuclear ophthalmoplegia. Key Words: Pontine hemorrhage-Traumatic brainstem hemorrhage-Traumatic internuclear ophthalmoplegia. From the Department of Neurology, LAC USC Medical Center, Los Angeles, California. Address correspondence and reprint requests to James R. Keane, M.D., 1200 North State Street, Los Angeles, CA 90033, U.S.A. 165 Trauma is an uncommon cause of internuclear ophthalmoplegia (INO). In 15 years I have seen six patients with bilateral INO and four with unilateral INO caused by head trauma. [A further seven patients with bilateral INO and two with unilateral INO resulting from tentorial herniation after trauma have been followed during the same period (1).] Reports of INO directly resulting from head trauma are somewhat difficult to tabulate, since INO may not be recognized as such or may be only incidentally commented upon. I am aware of 17 cases, mentioned in the literature, of probable INO following trauma (10 bilateral, 6 unilateral, and 1 unspecified) (2-7). In only one patient has the causative lesion been demonstrated (6). A large hemorrhage in the upper brain stem of the patient described here produced bilateral INO as the principal sign. CASE REPORT A 22-year-old man, intoxicated by alcohol and phencyclidine, was struck by an automobile while riding his bicycle on the freeway. On admission he was unconscious and showed a dilated, fixed right FiG. 1. Cumpu ed tomograpnlc scan views show a large central hemorrhage occupying the rostral pons and a small portion of the caudal midbrain. 166 J. R. KEANE Fr~. 2. Complete bilateral internuclear ophthalmoplegia is evident on gaze right (top) and left (bottom). FIG. 3. Magnetic resonance views in the saggital plane (top, T1 weighted) and coronal plane (bottom left, T1 weighted; bottom right, T2 weighted) show resolving pontine hemorrhage three months after injury. I Clill Nellro-ophthalmol, Vol. 7, No.3, 1987 pupil and extensor posturing of the left limbs. Computed tomography revealed a large central hemorrhage occupying the rostral pons and the caudal tip of the midbrain (Fig. 1), In 10 days he was following commands, and by the end of the second week he was talking, On transfer to Rancho Los Amigos Hospital, 1 month after the accident, he exhibited no medial rectus movement on lateral gaze (Fig, 2) or convergence. Other signs consisted of upward gaze nystagmus, mild confusion, and gait and left arm ataxia. Slow improvement continues 3 months following his accident. On horizontal gaze, the right medial rectus remains paralyzed, but the left medial rectus has recovered -20% of its range. Near fixation evokes modest additional adduction of each eye. Magnetic resonance imaging nicely delineated the resolving pontine hemorrhage (Fig. 3), A recent paper (8) also illustrates magnetic resonance imaging in internuclear ophthalmoplegia. REFERENCES 1. Keane JR. Bilateral ocular motor signs after tentorial herniation in 25 patients. Arch NeuroI1986;43:806-7. 2. Beck RW, Meckler RJ. Internuclear ophthalmoplegia after head trauma, Ann OphthnlmoI1981;13:671-5. 3. Falbe-Hansen I, Gregersen E. The prognosis for disturbances in ocular motility following trauma to the head. Acta OphthnlmoI1959;37:359-70, 4, Shimoyama I. Ninchoji T, Hiroshi R, Nakajima S. Kenichi U, Nozue M. Traumatic MLF syndrome, Neurol Med Chir 1981;21:321-7. 5. Davis RA. Traumatic decerebrate rigidity and neurological recovery: a case report. Neurosurgery 1983;12:569-71. 6. Shakir RA, Khan RA. Traumatic brain stem hematoma without prolonged loss of consciousness. Br I Med 1984;1:446-7. 7. Catalano RA, Sax RD, Krohel B. Unilateral internuclear ophthalmoplegia after head trauma, Am I Ophthalmol 1986;101:491-3. 8. Atlas SW, Grossman RL Savino PJ, et aL Internuclear ophthalmoplegia: MR-anatomic correlation. Am I Neuromdial 1987;8:243-7. |
