Abnormal Downward Gaze and Cold Caloric Examination Due to Propofol: A Case Study

Background: Adolescent patient with isolated abnormal downward gaze and oculovestibular (cold caloric) testing during propofol administration prompting concern of brainstem injury. PATIENT: An otherwise healthy 16 year old female presented after an intentional hanging. Brainstem reflexes were normal except that both eyes were in tonic downgaze on initial examination. Propofol was suspended for 30 minutes to evaluate level of responsiveness with eyes normalizing to midposition from tonic downgaze. With reinitiation of propofol, the eyes returned to the former position. C-collar stabilization prohibited oculocephalic (doll’s eyes) evaluation, and with cold caloric testing, eye movements were as follows: right sided cold water instillation resulted in right eye exodeviation to the right with minimal medial movement of the left eye to the right. Upon left sided instillation, the left eye deviated downward with minimal medial deviation of the right eye. Patient was weaned to extubation within 48 hours of admission, and off sedatives normal ocular motility returned. CONCLUSION: This patient manifested abnormal ocular motility and cold caloric exam with single-agent propofol exposure. The remainder of the cranial nerve exam was normal, and in the context of a normal brain and cervical spine MRI, the clinical picture was inconsistent with brainstem injury leading us to suspect propofol effect. This was supported by the return of normal ocular motility once propofol was discontinued. Consider pharmacologic disturbance of ocular motility and cold caloric testing in the absence of other brainstem dysfunction when concomitant propofol is administered