Michael W. Devereaux

Inter‐nuclear ophthalmoplegia caused by subdural hematoma

Internuclear ophthalmoplegia (INO) is caused by lesions in the median longitudinal fasciculus. It is generally the result of primary intraaxial disorders, most commonly multiple sclerosis in young adults and infarction in older adults. Rarely, extraaxial disorders cause INO by compressing the brainstem. We report two patients with INO resulting from subdural hematoma with transtentorial herniation. These cases demonstrate that INO is a reliable, but not a pathognomonic, sign of a primary intraaxial disorder.

Fulminant Idiopathic Intracranial Hypertension

Fulminant idiopathic intracranial hypertension is extremely rare but invariably is associatedwith permanent blindness unless there is prompt intervention. Hypothetically, a rapid increase in pressure in the perineural space around the optic nerve can lead to ischemic opticneuropathyandblindness.1An 18-year-oldoverweightwoman with rapidly progressive visual loss over 4 days (leading to no light perception), nonreactive pupils, binocular abduction deficit suggestiveof sixthnervepalsies,bilateraloptic-discedema(Frisenstage 5),2 and cerebrospinal fluid opening pressure at 600 mm H2O receivedadiagnosisof fulminant idiopathic intracranialhypertension.1 The results of cerebrospinal fluid laboratory studies,magnetic resonance imaging of the brain, and vascular imagingwere normal. Our Figure, AandB, showsmagnetic resonance imagingscansof thepatient’s orbits at the time of presentation. Anemergent,controlled lumbardrainwasput inplace,andtreatment with intravenous methylprednisolone sodium succinate and furosemide was started on the first day. Five days later, her visual acuitywas20/400 inbotheyes, herpapilledema improved, andher abduction deficits resolved. Our Figure, C and D, shows follow-up magnetic resonance imaging scans on day 5. A ventriculoperitoneal shunt was performed for relatively long-term control of cerebrospinal fluidpressure.Onday9, herpapilledema improved toFri-

Influence of orbital eye position on vertical saccades in progressive supranuclear palsy

Disturbance of vertical saccades is a cardinal feature of progressive supranuclear palsy (PSP). We investigated whether the amplitude and peak velocity (PV) of saccades are affected by the orbital position from which movements start in PSP patients and age‐matched control subjects. Subjects made vertical saccades in response to ±5° vertical target jumps with their heads in one of three positions: head “center,” head pitched forward ∼15°, and head pitched back ∼15°. All patients showed some effect of starting eye position, whether beginning in the upward or downward field of gaze, on saccade amplitude, PV, and net range of movement. Generally, reduction of amplitude and PV were commensurate and bidirectional in the affected hemifield of gaze. Such findings are unlikely to be because of orbital factors and could be explained by varying degrees of involvement of rostral midbrain nuclei in the pathological process.