Brain herniation and eye movement

Nurses General Nursing

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Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

I have been trying to look up the name of this eye movement, but have not had any luck. Any of you that have experience with this, please chime in.

Pt had massive global stroke, younger 50ish. I was reading the notes before I got this transfer and it stated that there was no herniation as of yet, but without surgery the MD's thought that it was likely that the brain would herniate.

When I recieved the pt, her eyes were moving like you were reading a book. It didn't matter if you opened her eye lids or if the lids were closed, her eyes were still moving back and forth like reading a book. I know this is a sign of brain damage, but would like to know the technical term for it if anyone knows what I am talking about.

Thanks!

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Specializes in ICU, Telemetry.

I had one of those and charted, "REM noted to L and R sides, continuous, not associated with sleep."

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Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

Everything that I am looking up mentions nystamus or abscent upward movement of the eye, but nothing that really describes what I was seeing.

Nerdtonurse, what was the diagnosis with your pt?

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it is called dolls eye reflex

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Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

actually her head was perfectly stationary. I thought that doll's eye reflex was only when you turned the pt's head and their eyes still looked forward rather than the normal responce which is to turn the eyes to the opposite side of the way the head is turned.

I think that I found my answer. From what I was reading it is Ping Pong gaze and when it stops is when the herniation reaches the brain stem and the pts die soon afterward.

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actually her head was perfectly stationary. I thought that doll's eye reflex was only when you turned the pt's head and their eyes still looked forward rather than the normal responce which is to turn the eyes to the opposite side of the way the head is turned.

I think that I found my answer. From what I was reading it is Ping Pong gaze and when it stops is when the herniation reaches the brain stem and the pts die soon afterward.

oh, sorry..i thought you were turning her head..misread post.

i'm very very tired, just trying to stay awake so i dont wake up at 4am again. almost 8pm..another hour i can go to bed and do me owm rem :yawn:

a patient i looked after who herniated on me had some brain tissue come through her nose. her face was so tight from swelling, i can still picture it like it was yersteday and not 18 years ago

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It's called Nystagmus.

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Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

sorry, forgot to put the "g" in nystagmus in the other post. Not enough coffee yet. ;)

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Specializes in Pediatrics.

What's the difference between nystagmus and a ping pong gaze?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

there are different kind of nystagmus depending on influence whether alcohol, injury, tumor, bleed or virus.

  • peripheral nystagmus occurs as a result of either normal or diseased functional states of the vestibular system and may combine a rotational component with vertical or horizontal eye movements and may be spontaneous, positional, or evoked.
  • positional nystagmus occurs when a person's head is in a specific position. an example of disease state in which this occurs is benign paroxysmal positional vertigo (bppv).
  • gaze induced nystagmus occurs or is exacerbated as a result of changing one's gaze toward or away from a particular side which has an affected vestibular apparatus.
  • post rotational nystagmus occurs after an imbalance is created between a normal side and a diseased side by stimulation of the vestibular system by rapid shaking or rotation of the head.
  • spontaneous nystagmus is nystagmus that occurs randomly, regardless of the position of the patient's head.
  • central nystagmus occurs as a result of either normal or abnormal processes not related to the vestibular organ. for example, lesions of the midbrain or cerebellum can result in up- and down-beat nystagmus.

opsoclonus refers to uncontrolled eye movement. opsoclonus consists of rapid, involuntary, multifactorial (horizontal and vertical), unpredictable, conjugate fast eye movements without inner saccadic intervals. it is also referred to as saccadomania or reflexive saccade. the movements of opsoclonus may have a very small amplitude, appearing as tiny deviations from primary position.

possible etiologies of opsoclonus include neuroblastoma and encephalitis in children, and breast, lung, or ovarian cancer in adults. other considerations include multiple sclerosis, toxins, or medication effects. it can also be caused by a lesion in the omnipause neurons which tonically inhibit initiation of saccadic eye movement (until signaled by the superior colliculus) by blocking paramedian pontine reticular formation (pprf) burst neurons in the midbrain. it frequently occurs along with myoclonus in opsoclonus myoclonus syndrome.

nystagmus is very noticeable but little recognized. nystagmus can be clinically investigated by using a number of non-invasive standard tests. the simplest one is caloric reflex test, in which one external auditory meatus is irrigated with warm or cold water or air. the temperature gradient provokes the stimulation of the horizontal semicircular canal and the consequent nystagmus.

doll's eye reflex is more correctly called the oculocephalic reflex. it is where rotation/flexion of the of the head cause transient eye movement in the opposite direction (lindsay, bone and calendar 1997 neurology and neurosurgery illustrated p30)

doll's eye reflex is only seen on unconscious patients and it only shows brain stem functioning so depending on the patient it can be a good sign - not good when it is the only sign still intact.

http://en.wikipedia.org/wiki/vestibulo-ocular_reflex

ping pong gaze

examination disclosed periodic eye movements with an initial downward deviation followed by rapid upward correction (dipping), which lasted 10 to 15 seconds (figure, a; video e-1, on the neurology web site at www.neurology.org). intermittently, these movements were followed by slow to-and-fro horizontal eye motion (ping-pong gaze) immediately or with a latency of several seconds

http://www.neurology.org/content/68/3/222.full

i hope this helps....:0

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And so long as we're at it, here's one more weird eye-movement thing associated with brains, or lack thereof. Cold calorics testing-- used to do this all the time with potential organ donors. Also had the interesting experience of feeling what this is like when my doc irrigated my ear with alcohol....cooooolllldddd.... and I felt my eyes jerrk uncontrollably. Weird.

From the Wikipedia:

Utility

It is commonly used by physicians, audiologists and other trained professionals to validate a diagnosis of asymmetric function in the peripheral vestibular system. Calorics are usually a subtest of the electronystagmography (ENG) battery of tests. It is one of several tests which can be used to test for brain stem death.

One novel use of this test has been to provide temporary pain relief from phantom limb pains in amputees [1] and paraplegics.[2] It can also induce a temporary remission of anosognosia, the visual and personal aspects of hemispatial neglect, hemianesthesia, and other consequences of right hemispheric damage.[3]

[edit] Technique and results

Cold or warm water or air is irrigated into the external auditory canal, usually using a syringe. The temperature difference between the body and the injected water creates a convective current in the endolymph of the nearby horizontal semicircular canal. Hot and cold water produce currents in opposite directions and therefore a horizontal nystagmus in opposite directions.[4] In patients with an intact brainstem:

  • If the water is warm (44°C or above) endolymph in the ipsilateral horizontal canal rises, causing an increased rate of firing in the vestibular afferent nerve. This situation mimics a head turn to the ipsilateral side. Both eyes will turn toward the contralateral ear, with horizontal nystagmus to the ipsilateral ear.
  • If the water is cold, relative to body temperature (30°C or below), the endolymph falls within the semicircular canal, decreasing the rate of vestibular afferent firing. The eyes then turn toward the ipsilateral ear, with horizontal nystagmus (quick horizontal eye movements) to the contralateral ear.[5][6]

  • Absent reactive eye movement suggests vestibular weakness of the horizontal semicircular canal of the side being stimulated.

In comatose patients with cerebral damage, the fast phase of nystagmus will be absent as this is controlled by the cerebrum. As a result, using cold water irrigation will result in deviation of the eyes toward the ear being irrigated. If both phases are absent, this suggests the patient's brainstem reflexes are also damaged and carries a very poor prognosis.[7]

Mnemonic One mnemonic used to remember the FAST direction of nystagmus is COWS.[8]

COWS: Cold Opposite, Warm Same.

Cold water = FAST phase of nystagmus to the side Opposite from the cold water filled ear

Warm water = FAST phase of nystagmus to the Same side as the warm water filled ear

In other words: Contralateral when cold is applied and ipsilateral when warm is applied

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

wow esme, that was a nice comprehensive review!

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