case_images: PMC11824529_01
case_images: T2-weighted/fluid-attenuated inversion recovery (T2/FLAIR) axial images at the level of pons (A), inferior colliculus (B), third ventricle (C), thalamus (D, E), and lateral ventricle (F). They illustrate symmetrically increased signal intensity detected at the dorsomedial thalami ((1)), inferior tectal plate ((2)), and periaqueductal grey matter within the dorsal midbrain ((3)). Furthermore, diffusion-weighted image (DWI) reveals heightened signal intensity present in both the bilateral dorsomedial thalami and inferior tectal plate of the dorsal midbrain.
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case_images: M3 segment, suggestive of arteriosclerotic change rather than vasospasm but did not show any evidence of aneurysm or stenosis as well as mass-like lesion in the brain. MRI showed symmetrically increased signal intensity on T2-weighted/fluid-attenuated inversion recovery (T2/FLAIR) at the dorsomedial thalami (Fig. 1D and E), inferior tectal plate (inferior colliculus) (Fig. 1B), and periaqueductal grey matter within the dorsal midbrain (Fig. 1A). It also showed diffusion-weighted image (DWI) high signal intensity in bilateral dorsomedial thalami and inferior tectal plate of dorsal midbrain (Fig. 1B, D, and E). MRI suggested abnormal findings of Wernicke encephalopathy and minimal chronic ischemic changes (Fig. 1).
case_images: Audiological testing. A: On hospital day 2, pure tone audiometry shows high-frequency sensorineural hearing loss in both ears. The hearing of mid-to-low frequencies are within normal limit. B: Loudness discomfort levels for pure tones are increased at all frequencies. C: Acoustic reflex appears normally in both ears to ipsi- as well as contralateral stimulation.
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case_images: Pure tone audiometry revealed high-frequency sensorineural hearing loss in both ears (weighted four-frequency average: 38 dB HL in right ear and 28 dB HL in left) (Fig. 2).
case_images: Due to the presence of ophthalmoplegia, the video-nystagmography (VNG) does not detect any eye movements during vestibulo-ocular assessments (A) of spontaneous nystagmus, positional nystagmus, and head-shaking nystagmus; and during ocular motor tests (B) including saccades, smooth pursuit, and optokinetic (OPK) nystagmus tests.
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case_images: Because of ophthalmoplegia, video-nystagmography (VNG) did not show that any eye movements did not occur in spontaneous nystagmus, positional nystagmus, head-shaking nystagmus, saccade, smooth pursuit, and optokinetic nystagmus tests (Fig. 3).
case_images: Video head impulse test (vHIT). A: vHIT exhibits reduced gain without overt/covert corrective saccade in all semicircular canals, especially both vertical ones. Decreased vestibulo-ocular reflex (VOR) gains are defined as <0.8 for the horizontal canal and <0.7 for the vertical canals. B: Conversely, the suppression head impulse (SHIMP) test yields reduced gain without anticompensatory saccade in both lateral semicircular canals.
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case_images: Suppression head impulse (SHIMP) test also showed reduced gain without anticompensatory saccade in both lateral semicircular canals (Fig. 4).