A 23-year-old woman presented with constant pendular vertical oscillations in primary gaze along with bilateral horizontal gaze palsy (Video 1) within 3 days of acute pontine hemorrhage (Figure). There was no palatal tremor. Gaze palsy was likely due to involvement of the paramedian pontine reticular formation. Pendular vertical oscillations (PVOs) after pontine stroke are a unique clinical finding initially described as “ocular myoclonus.” Pathophysiology of PVOs include (1) synchronized neural oscillations from the inferior olive after disruption of the central tegmental tract, (2) unstable integration of vertical gaze in the interstitial nucleus of Cajal from damage to the pontine paramedian tract, or (3) injury to omnipause neurons.1 Differential diagnosis includes ocular bobbing and oculopalatal tremor, both more common after brainstem stroke. However, ocular bobbing consists of intermittent fast downward movement with slow return to midline. Oculopalatal tremor is a delayed manifestation of injury to the dentato-rubro-olivary pathway manifesting as pendular nystagmus with vertical and/or torsional component synchronous with palatal tremor.2
Video 1
Continuous pendular vertical oscillations in primary gaze along with bilateral horizontal gaze palsy.Download Supplementary Video 1 via http://dx.doi.org/10.1212/207477_Video_1
Arrows indicate the site of hemorrhage. FLAIR = fluid-attenuated inversion recovery; SWI = susceptibility-weighted imaging.
Author Contributions
J. Ganguly: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; analysis or interpretation of data. S. Mukherjee: major role in the acquisition of data. N. Singh: major role in the acquisition of data. H. Kumar: study concept or design.
Study Funding
No targeted funding reported.
Disclosure
The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.
Acknowledgment
We acknowledge Dr. Mona Tiwari (Department of Radiology, I-NK, Kolkata) for providing MRI images and Dr. Divyani Garg (Department of Neurology, AIIMS, New Delhi) for the discussion.
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Resident and Fellow Deputy Editor Ariel Lyons-Warren, MD, PhD.
Teaching slides links.lww.com/WNL/C923
- Received January 22, 2023.
- Accepted in final form April 17, 2023.
- © 2023 American Academy of Neurology
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