Mal de Debarquement Syndrome (MdDS) is a prolonged rocking or swaying type of imbalance that occurs after lengthy exposure to motion, yet ensuing in the absence of motion. The provoking motion is most commonly following sea travel. MdDS has not heretofore been described in association with increased intracranial pressure. Such a case is presented.
Case Study: A 46-year-old female, with a history of hydrocephalus after infantile meningitis with ventriculoperitoneal shunt placement and multiple revisions, has a constant feeling of ‘rocking side to side’. One year and one-half year prior to presentation, she suffered two epochs of severe bilateral headaches coinciding with, as she describes, “the feeling of rocking, as if on a ship”. Both of these episodes were constant and lasted all day, progressively increasing in intensity for one week. During these events, she admits to nausea, but denied any vomiting, spinning, epigastric rising, or déjà vu or jamais vu. During the epochs there was no tinnitus, orthostatic hypertension, visual obscuration, loss of consciousness, syncope, seizures, weakness or falls. Prior to, or associated with the swaying sensation, she denies lightheadedness, pallor, salivation, blurred vision, tachycardia, visual auras or other neurological auras. There were no alleviating or aggravating factors, and were unrelated to position change, head movement, neck extension or rotation, coughing, or urination. She denies any recent air-travel, diving, sleeping on a waterbed, or alcohol use. In both epochs, shunt malfunction and associated increased intracranial pressure were discovered. Immediate resolution of the headache and dizziness episodes were achieved after shunt revision with correction of increased intracranial pressure.
Abnormalities in Cranial Nerve (CN) Examination: CN I: Alcohol Sniff Test: 14 (hyposmia). CN II: Visual Acuity OS 20/25. CN III, IV, VI: Saccadization of horizontal eye movement. Bilateral ptosis left > right. CN IX, X: Uvula deviated to the right. Motor Examination: Drift Testing: Left upward and outward drift with left Abductor Digiti Minimi sign. Reflexes: 3+ throughout.
Typically seen in middle aged woman, MdDS is a rare, self-limiting condition in which an abnormal sensation of rocking or swaying back and forth is perceived after exposure to air, car, land or sea travel (Nwagwu 2015). The phantom perception of self-motion occurs upon return to ground (Nwagwu 2015). This has been postulated to be due to maladaptation of the vestibulo-ocular reflex (Hain 2016) or disorder of connection between the entorhinal cortex and amygdala (Cha 2012). Increased intracranial pressure can affect the entire neural axis, including brainstem and cortical areas associated with MdDS. In those who present with intractable MdDS, measurement of intracranial pressure and treatment of any elevations may be warranted.