A 17 y.o. female came to the ED with vertical gaze paralysis
Our patient had neuro toxicity from Ifosfamide; the chemo agent she was being given for her sarcoma. It is treated with methylene blue. The methylene blue is thought to help because it inhibits monoamine oxidase which breaks ifosphomide into it’s toxic metabolite, chloroacetaldehyde,
While there are many causes of gaze palsies and paresis, they seem to have a common pathway. The posterior commissure, which is a white matter tract connecting the two hemispheres is involved and the medial longitudinal fasciculus in the brainstem which contains the interstitial nucleus of Cajal .
Disruption of nigrostriatal pathways, mainly functioning in dopamine metabolism by drugs such as neuroleptics causes decreased dopaminergic function and increased cholinergic function.
This can result in the most common vertical gaze palsy seen in the ED, oculogyric crisis. This was actually first described in 1910 in post parkinson’s patients but we see it most commonly as a complication of medications. Since the gaze abnormality results from decreased dopaminergic and increased cholinergic effects it is treated with antihistamines.
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Click directly on the picture above to see an oculogyric crisis from neuroleptics.
Because of the location of the vertical gaze control centers in the brain there are other causes of vertical gaze abnormality
STRUCTURAL LESIONS- pineal tumors can cause Parinaud’s paralysis of upward gaze. Hydrocephalus can compress the pineal recess. Strokes in the brainstem can also result in vertical gaze abnormality.
STORAGE DISEASES – Neimann Pick , gaucher’s
INFILTRATIVE LESIONS- sarcoid, Wilson”s disease
NEURODEGENERATIVE LESIONS- parkinson’s, huntington’s
INFECTIONS- involving the brainstem like Tbc, encephalitis/ paraneoplastic encephalitis and syphilis.
DRUGS- neuroleptics, carbamazepine, ifosphomide, compazine
Our patient was given 50 mg of a 0.5% solution of methylene blue and her symptoms resolved over several hours.
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Solberg M, Koht J. Oculogyric crises. Tremor Other Hyperkinet Mov (NY), 2017;7:491.
Reminton G, Voineskos G, Pollock B, et al. Prevalence of neuroleptic-induced dystonia in mania and schizophrenia. Am J Psychiatry 1990;147:1231-33.