 We're about ready to to get going here. We're happy this morning to have one of our. We're happy this morning to have one of our neurology residents here and Marie Collier. She's going to be talking a little bit of a Paranod syndrome and an exciting note about her is that she just got a new house in the area. So big big deal for Anne Marie. Thanks. Thank you for the opportunity to present this morning. Have a patient that was referred to neuro ophthalmology clinic. She's a 21 year old female who was in rehabilitation. She had been on the rehabilitation service for about two months. She had been previously healthy. She was struck by a motor vehicle while cycling. She did suffer a left temporal intracrimal hematoma, a small injury to the splinium of the colosum. An EVD had to be placed secondary to swelling, extra ventricular drain secondary to brain swelling at an outside hospital. She was transferred. She was going to school, I believe, up in Provo and she had also been trach and peg dependent for several weeks. She again was referred to us because of Diplopia as well as a left lateral rectus palsy. So on her neurologic exam, one of the things that she did notice was cognitive impairment. She perseverated, had word-finding difficulties. She did have some left-sided facial asymmetry, flat nasolabial fold, but otherwise, except for the ophthalmologic exam, her cranial nerves were normal. With motor incoordination, she did have left-sided pronated rift. She had difficulties with dexterity and coordination of her hands. She did not have any cerebellar signs. This is Mitra, her tremor, but she was from the left. She had a wide-based, unsteady gait. She could not walk tandem without stepping out and she also had a positive rhomburg on her ophthalmologic exam. Her visual acuity was 20 over 60 OD and 20 over 200 OS. This was the tumbling ease. Her pupils were slow to react to accommodation and non-reactive to light. Bilaterally, she had anisocorrhea with the left side larger than the right. Her visual fields appeared to be full to finger-counting and with her extractiluminescence, she was negative five with left abduction and negative three with right abduction. And she could not, she had paralysis of up gaze, bilaterally with no difficulties with down gaze. She did have pronounced convergence with two beats of convergence, retraction, nystagmus, on attempted up gaze and down gaze was preserved. She had a bilateral lid retraction in primary position and enhanced in down gaze. The funduscopic exam was unremarkable with the exception of a pale disc on the left. So you can see when she attempts to look to the right, when she attempts to look up. Good job. Okay, now look down. Down gaze was preserved. Okay, now look at my thumb. One of the things I regret is with this not using an okay-in drum or filming it from the side. I'm going to just switch sides here. If you look online, you can see some of the convergence and retraction nystagmus to seem better when you film them from the side. And you can actually see the orbit appear to retract in the globe. And you can see that she has pathologic lid retraction. Again, up gaze. It's hard to appreciate because she tends to look up with her whole head when she looks up. So we looked at the MRI of her brain and this was from the outside hospital. This was actually at the time. This was about four days after her injury. The EVD had been placed so you can see. What I wanted to try and demonstrate here was kind of a scrolling of the EVD. So you can kind of see it penetrate here and it's starting to go through. And then it goes into the ventricle here. Then it goes through the ventricle and then into the dorsal midbrain. And you can see that she's had an injury here, the left temporal lobe injury. But you can see right here that the EVD actually penetrates in the dorsal midbrain there. You can see it better with the sagittal. So it goes through the tectum and then the superior and inferior colliculus. And it actually appears to be resting in the inferior colliculus. So it was a very anatomically discreet placement of the EVD that led to her constellation of symptoms that basically make paranoics. So with perinods, she has paralysis of up gaze. So you have external ventricleogen. So impairment of upward gaze, eye movements, saccades and pursuits, down gaze as in our patient is preserved. Patients can have a setting. Sunsigns is frequently seen with neurosurgical patients who have hydrocephalus that they've had a shunt failure. They'll have a setting sun sign where the eyes deviate chronically downward with an apparent downward gaze preference. They have pupillary abnormality, opiations of pupils dilate for distant target but constrict for near target. Accommodation reflexes present, the light reflexes absent. With her it was really hard to appreciate because she would look up every time we had her. The eyes appear to actually jiggle. So when the patient attempts to look up, the attempt to up gaze causes convergence in the globe to retract within the orbit. It's an eyelid abnormality and it's pathological retraction as she looks perpetually startled. That's the convergence. So typical causes of dorsal mid-brain syndrome or intrinsic causes would be tumor. Then you have extrinsic etiologies which would be trauma as in our patient's tumor, placoductal stenosis with dilatation of the serum. So for prognosis and treatment, typically treatment is directed at, but we did recommend re-evaluating but these are some of the references.