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Show Divergent-Convergent Eye Movements and Transient Eyelid Opening Associated with an EEG Burst-Suppression Pattern Keyin R. Nelsl)Il, M.D., Richard P. Brenner, M.D., and Thomas J. Carlow, ~1. D. :\ nt'l)n.1tl' Inth .111 mtral'cntricular heml1rrh.1gc dCVl'I,) ped tralblcnt CI'did l)pCl1Ing and dil'crgcnt-cl1l1\'crgent el'e mlH'emt'nh assl)ciated with an EEe burstsuppressilm pilttern, These ocular ml)\'emt'nts mal' represent a brainstem release phenomel1l1I1, From the Neurulogy Service, AlbuljUl'rqul' Vl'Il'r.lf)' AdmInistration Medical Center dnd Depdrtml'nt ot Nl'llrologl', UnIversity of New Mexico School of Ml'dillJw, Albllljlll'rqlll', Nl'W Mexico. Address correspondence and reprint reqlll"h to fo.:l'vin R. Nelson, M,D, Departmt'nt of Neurtllogv, Albl'rt Il (11,1nd"'r Medical Center, University of Kentuckv, L",ington, KY .t(ISlh- 0084, U.5A . . 43 Clinically, divergent eye movements are rare. Cogan described a case of divergent nystagmus in a IS-vear-old mall' with a midline cerebellar tumor (1), The nystagmus began with a slow drifting convergence followed by a rapid correctional divergence, Yee and colleagues (2) found divergent nystagmus in two patients with downbeat m'stagmus, One had Arnold-Chiari tvpe I malformation and the other olivopontocerebellar degeneration, Paralysis of normal divergence has been seen with discrete lesions in the peri-aqueductal grav between the inferior and superior colliculi (3), Cortical lesions have produced divergent parah'sis in the presence of increased intracranial pressure; vergence returned when the intracranial pressure was lowered (4), Transient e\'elid opening in associatil1l1 with an EEC pattern of burst- suppressi,)n has infrequentlv bl'en described. I\lcCartv and Marshall (5) reported fi\'l' patients (l)Ill' child ,lnd fllllr adults) in whom rapid evelid llpening followed b\' slo\\' eyelid closure cnrrespnnded tn the nnset and terminatil1l1 of the EEC bursts, Twn adults with similar EEC and clinical findings were subsequenth' r,'pnrll'd (b,7) ,lIlel, like the pre\'ious patients, had suffered ,m ,lIlll'\ic insult. Of these seven cases !sever,ll others h,l\'l' been Illentil)ned; howe\'er, further dl'lails Wl'I'e Iwt gi\'en (8)], two exhibited vl'rtic,ll eve Illnvt'Illents in additinn to evelid npening, We report a neonall' who sustained an intraventricular Iwnwrrh,lgl' and had a burst-suppression EEC p,lttl'rn with e\'l'lid opening and divergentconvergent l'ye Illnvements assnciated with the bursts, This tvpe of eve movement has not been prl'viously dl'scribed, .J.J 1\, I( NIJ.'1( >N /T 1\/, CAsr I{I.:!'ORI :\ \'i- III \h l\l'I,1-- ,~I,-.t.llilll1,d .I,~l', 2, 'iIIlJ-g Ill,dl' \\',1" I'llm III ,111 1I1-'ldll1 dl'I'I'lhll'll1 dl,d",til I1Hlll1l'r, I \'\lrlll',lrdl.l, l\',IIHI-.,-., ,ll1d hq'"l',lIll'llli.l \\'l'rl' d"l'llllll'l1il'd ,II 1'11'111 ()Il d,I\' 2, h\'I',lIl'I1-.llIl1, -'\'-" tl'lllil ,hlllll-"-', .Illd 111\ lIllllllll l11l1\'I'IIH'I11-. dl'\'I'I· ,ll,,'d q h ,lllt'r "lIr~~il,d lllnnlllllll.1 hi-. l.lrdl.ll dl" It'd", I hl' ,ll1tl'rllIr 1,,"1.1111'11\.1-.111111 ,1I1d 1'1I1-.,tldl', tl1l' Irlll1!lI'llllll'it,d lUl1I1ll1l'Il'lhI' \\'.1-' '\2 'i lll1 11,-. V\'l'-' lll'l'111'd I" 1'.I111lui -.llllluli 111l' I'lIl'd-. \\'lTl' '\ Illlll bd,ltlT,llh' .ll1d 1l'.It'1l'd 1111rlll,11h' tll 11,~ht :\ right hq'vrlrlll'I.I \\,.1-' 1'1l'-'l'111 ill 1'1'1111,11'\' g.l/l' l:rvqlll'llt dl\l'l',~I'l1t- llll1\l'r,~I'llt l'\l' 1ll1l\1'IlH'llt-. l'ccurn'd, JllIrI/lIlll.l1 lllUlllll'l'h.l111 1ll,1Ill'U\l'r" 1'1'l.,hICI'd Iilllill'd ,1ddudlllll (),I) ,1Jld dlll\'IlI\',Hd dl'\'i,llillil 1\'Ilh ,1 -'UI'VrJllll'll'-l'd Cllll'I--\\'j-'l' tllr-'Illil U,~ hllldu"Cllpil' l'\,lI11ill.ltilln -.hlll\'l'd loHgl' "I'tIC CUI''' \\'ith pl'rJp,ll'ill,H, dlllrlliddl. .Illd rdin.ll dl'gl'lll'r, ltilln, ClIrlll',d rl'lll'\l'" \\'l'n' Illlrlll,ll. Crilll,lll' III dn,!, I"lill ,1Jld Illud d'lp \\',1" "\'Illllll'tric, ll. ~VIl-',ltl"ll ,11ld 1ll1l\'I'Illl'Il! I\'vrv Illt,ld ill ,111 I"ur l'\trvillitil'-' D,"'p ll'lldllll rl'lll'\l'-' I\'l'rl' pn'''l'llt ,llld l'qu,d, \l\'lIClllllic Illll\'l'Il11'1l1-. llCcunl'd \\'hich \\'vrl' ,~l'lll'r,lli/l'd III' clluld ill\'lIhl' al1\' l'\trl'lllitv ill i,,"I,ltilln, lrl',ltnll'nt \\',1-. bl'gun \\'ith \',hlll'rl'-'-'llr ,1gl'llh, ~lldiulll bic,Hbllll,ltl', ,llld l'hl'llllboHbit,11; [)il.1ntin \\',1" ,lddl'd I,lll'r. CT "C,lll rl'\'l',lfl'd ,1 I,Hgl' illlr,l\' l'lllricul,lr hl'llll.nh,lgl' ,llld Illlldl'r,lll' hnirllcephalu~ (Fig", Ll,b), Cl'rl'bnl"pill,l! fluid (C~F) culturL'-' \\'l'rl' Ilq~,lti\'l', 1\ 2-h, IK-channel EEC on day 3 showed a 1l1lIlrl"lCti\'l' discontinuous pattern with high-amI'litudl' 1- to 1-0, bursh 01 sharp waves and spikes ddllli\l'd \\'ith slo\\' \'\',lVl'S, followed by 5- to 30-s I'l'riod-. 01 l'l'rl'bral suppreo,sion, With most bursts tl1l' I',dpebral ti..,o,ure.., widenL'd, and the pupils diIdtl'd dlld bl'canll' sluggishly rL'active to light. Eye 1ll0\'l'llll'llh \\'l're ,l!<,O ,1SSOCiillL'd with the bursts, 1"lIl1\\'l'd l'\'l'lid opening and persisted for 3-15 s (Iig, 2), I hl'\' con..,istl'd 01 an initial rapid divergl'/ H'l' 01 I:; - 2( I dl'grL'l'''' lollowed by a slow con\' l'rgl'ncl' Ucular mO\'l'ml'nts (,(curred only with till' bursh, and mo..,t bursts WL're accompanied by l'\'l' 111l1\'l'llll'nh /\pproximatl'h' half of the burstrl, l,ltl'd l'\'l' mll\'l'menh 1\'L'rt' a~so(iated with eitlwr Illcai llr gl'lll'ralizl'd m\'llC!onic jerks, SubclinIC, ll l'kctrographic Sel,lUrl' di..,charges were seen ll\l'r the Idt IWnll,;;pherl:' e\'l'n' 3-11 min and I,l"tl'd 1(11' 1-2 min, Intr,l\'en(lu~ diazepam (0,7 nlg "g) nl,HI--l'dh- rl'ducL'd the lIccurrt:'nce lIf bursts ,lnd lICUI,H nlll\'l'IllL'nh. ,lnd IL'ngthened the perilld-. lI1 ~'lTl'br,l! -.uppn'-.-.ilIl1 (uP t(l ·r ~ min), TIll' dl\l'rgt'nt-clln\l'rgl'nt l'\'l' nll'\'ements re-' ll!\l,d within ~h h ,11lL'r lln-.l.'l, :\t 1 mllnth of age, till' poltil'nt explrl'd bl'C,HI';l' (Ii 'l\'en\'helming ';l'p"i", including Bl.'l,l "tfl'pt('CII((,ll ,lnd P",t'lIdll1I1l1l/,/- ilt'rU'-:IIIl " 1' Illl'ningiti", AUTOPSY FINDINGS 'I hl'rl' I\l're Cllll,~l'nltoll 111,11Il'rnl,ltil)n~ of the Ill'Mt, gn',lt \l'''-'l'!~, ikul11, ,lnd ldt ureter. The turbid ,lnd thicl-- CSF ,lnd Iq'tl'nwninges were (a) (iii) t-lli. 1. (a) Intraventricular hemorrhage (greater on left) and hydrocephalus (b) Extension of hemorrhage Into the fourth ventricle \ "~I I- \" I 1"'-';" D/Vf.l<.CLNF-CONI'I'/'l;/NI EYL MOVEMENTS 45 Fp 1-F3 ,-~ '~"''''' " // ---_.... I . ) I I, . - f ' J- -' --' ',I";'\:Y~~'~~-"~ It; '>.' .' J. _ \1 ',J \,\' . "j llJ I'r C3-P3 F3-C3 L1C-LOC RIC-ROC P4-02--. P3-01 Fp2-F4 F4-C4 C4-P4 ,.' ,1 (~ I~\:'~~\/""'----~~ -'~-"'\" '.\ .,--~-"'---~---,_.._,.,,'~---""'--.-I'-~~~.-----.r \ \ \ "I r"" . 'Jc - .-_0 .,,_.-.-- -_~~ ~._ FIG, 2. Generalized burst followed by suppression Divergent-convergent eye movements are seen in the top two channels. Divergence produces an upward pen deflection: convergence, a downward deflection. Rapid divergence and slow convergence are evident. (L = left. R - right. IC = inner canthus, OC = outer canthus.) H>lkH\·-green. Fibwsis of the leptomeninges was most marked lIver the inferior cerebellar surf,lCe and the brain stem. The cortical surface was collapsed o\'(>r the left parietal lobe. The cerebellum sho\\'ed atrophic folia and a loculated subarachnoid hemorrhage over the left hemisphere, Coronal sections of the cerebral hemispheres disclosed extensive bilateral cavitarv necwsis throughout the peri ventricular white matter, most severe in the left parietal and temporal lobe~. Coagulum from the previous intraventricular hemorrhage was present in the left frontal and tl'mpor,ll horns. Sections of the midbrain, pons, dnd Cl'rl'bellum revealed no gross abnormalitie~other than a leptomeningeal exudate and coagulum within the aqueduct of Sylvius. Microscopic sections of the cerebral hemispheres showed disruption of the ependym,11 w,lll of the lateral ventricles with subependvm,ll gliosis and laminated blood clot within the ventricles. There was a subacute and chronic infldmmatorv leptomeningeal infiltrate of macrophages ,1I1d ,1 few granulocytic leukocytes, with bactl'rial colonization and subarachnoid hemorrhdge. The midbrain, pons, medulla, and cerebellum showed the same type of meningitis pnd blood in the cerebr,ll aqueduct. There were no parenchymdl br,linstl'm lesions. COMMENT Two previously described patients with transient eyelid opening and a burst- suppression pattern had associated eve movements. McCartv and , , Marshall (5) reported a ,F>~'ear-old girl (their case 1) who had vertical eye mo\'ements. Mori et al. (7) noted upward eye movements in their patient which they believed were similar to those of postencephdlitic parkinsonism, Epill'ptic eve nWVl'ments are l)ften horizl1I1tal and conjugate, with the fdst ph,lse usuall\' contralateral to the discharge silt' (Y,IO). Other epileptic eve movements include nvst,lgmus retractorius (II, 1~). ~'lt'ndul.u nvstagmus (9,13), and torsional nystagmus (I.l). To our knlHdedge. epileptiform EEC ,1ctivitv has nl1t been llbserved with ocular vl'rgence. In llur p,ltient, the divergent-cl1n\'ergent movements Wl're ,1ssociall'd with the bursts and continued during tOerl'bral suppressil)n. Some cases of epileptic eve mOVl'l11l'nts had a direct correlation of nyst,lgml1id oscillations with EEC discharges (10, IJ); otl1l'rs h,we not (';I). The temporal association of EEC ,1Ctivitv ,wd eye n1llvel11ents usually suggests when eve movements are epileptic. Neverthelt'ss, the divergent-convergent eye moveml'nts in our patient pwbably do not represent a 1011I NC"Y<'-"I'hth'lill/ol, Vol. 6, No.1, 1986 1\. I~. Nt.LSON [1' AL. seizure. MeeHtv ,1I1d Mdfsh,111 ("i) felt that the eVt'lid ll~1l'ning :lI1d dllSUfl' assllciakd with the b'ursts in their caSt'S t'ould be ,1 br.linslt'm release pht'llllmenlln. TIll' S,lme e\ pl,ln,1 tion for divergl'nt- cllnvl'rgl'nt eve 1110Vl'I11l'nts in our p,1tient \\'\luld be C\lnsistt'nt with sevl'r,11 recent studies (("i-IS) llf Iwon,1t,11 "seizures" which SUggl'St that vdfi,lllS mllVt'ml'nts resembling clinic,11 seizure activit\' m,l\' be n\lnl'pikptic Primitive beh'lVior st'el~ in n'elln,1tes m,lY be elaboralt'd within tht' brain stem and rell'ased bv fllrebrain depression (15), A burst-suppression EEG pattern indicates severe functional involvement llf corticell and subcllrtical structures (19). Divergence and convergence cells are intermixed in the mesencephalic reticular formation near the oculomotor nucleus (20). Release of these cells due to forebrain depression may have caused the divergent-Cllnvergent eye movements observed in our patient. REFERENCES 1. Cogan D. G . Convergen,-e m"tagmU',: Wilh nol,', "n .I single case of divergt'nc,' nystagmus. Anll. 0,,11111,,111I,,1, 62: 295-299, 195'-1 2. Yee, R. D, Baloh, R. W, H'1I1rubia, V, and Jenkin" H, A,: Slow buildup of optokinetic nYstagmu, a~,,'cialL'd with downbeat nystagmus. 1!H'esl. O"III11I111'll.l. \ ',',"ll ~d 18: 622-629, 1979. 3. Bender, M. B., and Savitsky, N : rarah'S1~ 01 di\'l'rgenc,'. Arell. 01'"II,allll"I, (Chic.) 23: lO4b-1l151: 1'-I4L1, 4. Chamlin, M., and Davidoff, L. 1'...1.: Di"ergencl' par,lh'~I' and increased intracranial pressurl', /. ;,\/,'11 r",11 '.\ , 7: 539-543, 1950 5 McCarty, G, E" and Marshall, D, W.' TranSlt'nl ""el,d opening associated with postan,'\ic EEG ,upprl's,ionburst pattern. A,dl. Nt'II'''/. 38: 754-75b, I'-ISI. h, J"rdan, J E., Parrish, D, C, Cliett, J B, et al.: Suppression burst assoc;at,'d with eye opening, (Letter.) Arcll. Nell ",I , 39: h02, IYX2, 7, Mori, E" Yamadori, A., Tsuruta, H" et al.. Transient eye opl'ning with EEG suppression-burst pattern in postanoxic l'nn'Phal"pdthy. (Ll'tll'r,) Arcll, NellI'''/. 40: 1!:S9, 19H3. X Marshall, D. W" dnd McCarty, G. E.: Transient eye op,'ning with EEG suppression -burst pattern in postan" xic l'nc''Phalllpathv-ln rl'ply (Letter.) A,ch, Nfl/rol, 40: IX'-I-IYII, IYX, '-I Wh,fl', I C. Epill'ptic nystagmus, [I""y;ia, 12: 157-164, IY71 III Ill-un, /I. M" Bcint,'md, D, J" Binnie, CD., et al.: EpiIl'pll' l1\'stdgmu' 1'1""'1"",25: h04-h14, 1484, I I Brl'nnl'r, r< f' , dnd CHllIw, T, J: PLEDS and nystagmus rl'lr,ILt"nu' :\/1/1. .\','11",1 5: 40], lY74, 12 Young, (, IJ, Brown, J D" Bull"n, C. G" and Sibbald, W \.1 I','n"dic Idtl'r,llizl'd epileplJlorm discharges (PLL.Ds) and nl',ldgmu, rl'lract"rius. Al/l/ NCllrol. 2: h1-h2,IY77 ' IJ Wdtanabl', ", .'\,l'gllr", T , ,\latsumoto, A" et al.. Epileptic n,'stagmu' a""cldtl'd h'lth tlTlCal absl'nce seizures. [1';' It'jh/ll 25: 22-2~. l'1x~. 14 H"rita, H, H"a,hl, L, (l!<uI·ama. Y, tel al. The studies of Ihl' dttack, lIf abn"rmdl"I't' m,,' l'ml'nt in a ca~e of infantile spdsms 1,,1,,1 1"ltd""'r\.',·u,,,1 /,,,, 31: J'-IJ-402, 1977. 1, \.I,uah;, E .\1. and ""'I,lI"dl, P "St'I/ur,"" "i neonates and I'llung Inldnts hJlh Jnd h"t11tJU t accllmf'am'ing EEG l'pil,'ptl!<'rm acll\lt,,, An EEC f'"!.' ...~raphlc "dl'lI moniI" rlng ,tudl' 1,1,,1<'1"'" 25: hhi'i, IYi'i~, Ih . .\lluahi, E' .\1, and "CIlJhal, P.: Characterizati,'n of seiLUrl'~ in neun..lt~·", ,Jnd \·\lun~·lnfant.... Q" tinle- .... \'nchronizt>d electwencephaiL1gra p i'lIc p,'!."grarhlc I Ide" monitoring, ,~I/I/ '\"eu,,)/, 16: 3i'i3, !Yi'i4 17, Sh"h'm'lIl, D .-\ , DI'''·'(lali,.n petht'en (,'rti(al discharges and iLIa I mll\','ments In nl','n,lt,ll ,,'I/url'S. ,4'''1. ,\','11",1 14: 3bS, 1%3. IK. Danner, R, Sherm,)n, ,-\. and Serman, \1 P.: Seizures in an afl'lencephalic Inf,lnt. I, the (,'rt,'\ e",'ntlal f,'r ne'1I1atai Seizures' ,''H,'', \e,,,','! 42: Ii.Il~-I'.II", 14:-;;, IY. Kur');h'd,) CeleSl,l. C C. Clint(al Significance l,i peri- ,'dlc EEe f',lltl'rn' .,\"./, .\,'1''-'': 37: );-20, 14Sl). 20. td\''';'. L. E.: ~<t'ural Ll1ntrl)! tit \·l.'r~l'n(l' l'\'t:' rnln·t..'ment~: C\)~l\·t:'r~t.lnl.·l) ~lnd dl\"\.'q.:,,,·nce nt:'lIrt~n .... In n{idbrain. I..\'t'll"",/ 111,,<,1.51: Itl4 1-llll,-;. 14,,-/ |
