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Images in Neurology
August 12, 2019

Ocular Dipping in Anoxic Brain Injury

Author Affiliations
  • 1Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
JAMA Neurol. Published online August 12, 2019. doi:10.1001/jamaneurol.2019.2393

A patient in her early 50s with a history of hypertension, diabetes, and new-onset heart failure experienced multiple cardiac arrests. Continuous electroencephalogram results showed occasional left frontal periodic discharges with superimposed generalized slowing; periodic discharges were ameliorated with levetiracetam, 1 g twice daily. Magnetic resonance imaging results of the brain found a diffuse anoxic brain injury involving the basal ganglia and cerebral cortex (Figure). During a consultation for postarrest encephalopathy, the patient was unable to respond well, follow commands, and move her limbs purposefully, with only minimal limb withdrawal to noxious stimulation. Her eyes were open and she showed spontaneous frequent nonrhythmic, synchronous slow downward conjugate eye movements followed by a faster upward jerk, consistent with ocular dipping (Video). The dipping movements occurred more frequently during passive limb movements and noxious stimulation. She had superimposed conjugate roving horizontal eye movements and her brainstem reflexes were intact. Serial examination results were unchanged, with no signs of environmental interaction and persistent ocular dipping.

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