Movement Disorders Vol. 5 , No. 2, 1990, pp. 139-142 0 1990 Movement Disorder Society
Gaze-Evoked Involuntary Movements K. D. Sethi, D. C. Hess, *R.C. Harbour, and G. L. Holmes Departments of Neurology and *Ophthalmology, Medical College of Georgia, Augusta, Georgia, U.S.A.
Summary: Voluntary gaze may evoke a number of neurological phenomena such as vertigo, tinnitus, blepharoclonus, eyelid nystagmus, “facial nystagmus,” involuntary laughter, and seizures. We report two patients in whom eccentric gaze evoked facial twitching and arm movement. Electroencephalograms remained unchanged during these movements. The pathogenesis of these movements is unclear but may involve ephaptic transmission. Key Words: Eye gaze-Involuntary movements. -
the distribution of the right trigeminal nerve, and jerk nystagmus on looking to the right. He exhibited marked right-sided ataxia. Sustained extreme rightward gaze resulted in irregular twitching of the right face, platysma, and clonic movements of the arm and shoulder muscles. The movements disappeared immediately on reassuming primary gaze (Fig. 1A and B). The latency between rightward gaze and onset of the movements varied from 5 to 20 s. These movements did not occur on primary gaze or partial rightward gaze, even when sustained. There was no change in the movements on distracting the patient. The patient was fully conscious during these movements. An electroencephalogram (EEG) obtained during these spells remained unchanged. Carbamazepine markedly improved the arm jerking at a blood level of 7.7 pg/ml. Discontinuation of carbamazepine resulted in the reappearance of the movements. A magnetic resonance (MR) scan (Fig. 2A and B) showed an area of high signal intensity on T2-weighed images (TR = 2,000 TE = 80) in the right cerebellar hemisphere, superior cerebellar peduncle, and pontine tegmentum consistent with an old infarction.
Voluntary ocular movement may evoke a number of neurological phenomena, including vertigo (l), tinnitus (2), blepharoclonus (3), eyelid nystagmus (4), “facial nystagmus” (3,involuntary laughter (6), and seizures (7-9). We report two patients in whom sustained eccentric gaze evoked involuntary facial and arm movements. CASE REPORTS
Patient 1 A 64-year-old man had a pulling sensation in the right side of the face with intermittent right arm twitching for 12 years. Twenty years previously he had rapid onset of right facial numbness, unsteadiness, and headache and was suspected to have a cerebellar tumor or hemorrhage. He underwent a posterior fossa craniotomy , which revealed a cerebellar infarction in the anterior inferior cerebellar artery territory. Since then he has had facial asymmetry and difficulty using the right hand and leg. Neurological examination revealed a miotic right pupil and a mild ptosis of the right upper eyelid. Facial sweating was intact. He also had slurred speech, decreased pinprick and touch sensation in
Patient 2 A videotape segment accompanies this article. Address correspondence and reprint requests to Dr. K. D. Sethi, Department of Neurology, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912-3200, U.S.A. Results of this study were presented at the 40th Annual Meeting of the American Academy of Neurology, Cincinnati, Ohio, U.S.A. in 1988.
A 66-year-old man had intermittent dizziness, sometimes provoked by sudden movement and accompanied by nausea and salivation for 2 years. Neurological examination revealed no nystagmus and minimal heel-to-shin ataxia and difficulty in tan-
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dem walking. He fell backward on eye closure in the spite of normal proprioception in the feet. On looking down he developed, after a delay of 1-3 s, irregular twitching of muscles over the zygomatic arch that occasionally spread to involve the mentalis muscles. These movements were bilateral but asynchronous. He did not develop ocular nystagmus. On reassuming primary gaze these movements stopped immediately. Electronystagmography revealed spontaneous left beating nystagmus (
Gaze-Evoked Involuntary Movements K. D. Sethi, D. C. Hess, *R.C. Harbour, and G. L. Holmes Departments of Neurology and *Ophthalmology, Medical College of Georgia, Augusta, Georgia, U.S.A.
Summary: Voluntary gaze may evoke a number of neurological phenomena such as vertigo, tinnitus, blepharoclonus, eyelid nystagmus, “facial nystagmus,” involuntary laughter, and seizures. We report two patients in whom eccentric gaze evoked facial twitching and arm movement. Electroencephalograms remained unchanged during these movements. The pathogenesis of these movements is unclear but may involve ephaptic transmission. Key Words: Eye gaze-Involuntary movements. -
the distribution of the right trigeminal nerve, and jerk nystagmus on looking to the right. He exhibited marked right-sided ataxia. Sustained extreme rightward gaze resulted in irregular twitching of the right face, platysma, and clonic movements of the arm and shoulder muscles. The movements disappeared immediately on reassuming primary gaze (Fig. 1A and B). The latency between rightward gaze and onset of the movements varied from 5 to 20 s. These movements did not occur on primary gaze or partial rightward gaze, even when sustained. There was no change in the movements on distracting the patient. The patient was fully conscious during these movements. An electroencephalogram (EEG) obtained during these spells remained unchanged. Carbamazepine markedly improved the arm jerking at a blood level of 7.7 pg/ml. Discontinuation of carbamazepine resulted in the reappearance of the movements. A magnetic resonance (MR) scan (Fig. 2A and B) showed an area of high signal intensity on T2-weighed images (TR = 2,000 TE = 80) in the right cerebellar hemisphere, superior cerebellar peduncle, and pontine tegmentum consistent with an old infarction.
Voluntary ocular movement may evoke a number of neurological phenomena, including vertigo (l), tinnitus (2), blepharoclonus (3), eyelid nystagmus (4), “facial nystagmus” (3,involuntary laughter (6), and seizures (7-9). We report two patients in whom sustained eccentric gaze evoked involuntary facial and arm movements. CASE REPORTS
Patient 1 A 64-year-old man had a pulling sensation in the right side of the face with intermittent right arm twitching for 12 years. Twenty years previously he had rapid onset of right facial numbness, unsteadiness, and headache and was suspected to have a cerebellar tumor or hemorrhage. He underwent a posterior fossa craniotomy , which revealed a cerebellar infarction in the anterior inferior cerebellar artery territory. Since then he has had facial asymmetry and difficulty using the right hand and leg. Neurological examination revealed a miotic right pupil and a mild ptosis of the right upper eyelid. Facial sweating was intact. He also had slurred speech, decreased pinprick and touch sensation in
Patient 2 A videotape segment accompanies this article. Address correspondence and reprint requests to Dr. K. D. Sethi, Department of Neurology, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912-3200, U.S.A. Results of this study were presented at the 40th Annual Meeting of the American Academy of Neurology, Cincinnati, Ohio, U.S.A. in 1988.
A 66-year-old man had intermittent dizziness, sometimes provoked by sudden movement and accompanied by nausea and salivation for 2 years. Neurological examination revealed no nystagmus and minimal heel-to-shin ataxia and difficulty in tan-
139
140
K. D.SETHI ET AL.
dem walking. He fell backward on eye closure in the spite of normal proprioception in the feet. On looking down he developed, after a delay of 1-3 s, irregular twitching of muscles over the zygomatic arch that occasionally spread to involve the mentalis muscles. These movements were bilateral but asynchronous. He did not develop ocular nystagmus. On reassuming primary gaze these movements stopped immediately. Electronystagmography revealed spontaneous left beating nystagmus (
