Aberrant regeneration of the oculomotor nerve followed by intracranial aneurysm: case report

To report a case of aberrant regeneration followed by acute palsy of the oculomotor nerve caused by intracranial aneurysm. A 59-year-old patient was attended in February 2006 complaining of headache with diplopia and blepharoptosis in the right eye. At the external ocular motility exam. Aduction, supraduction and infraduction defects with blepharoptosis in the right eye were observed. Regarding the internal ocular motility, mydriasis in the right eye. Acute palsy of the oculomotor nerve in the right eye was diagnosed and neurological examination was requested. At the Department of Neurosurgery, after having diagnosed aneurysm of the posterior communicating artery, the patient was submitted to an operation. In December 2006, it improvement of the aduction was observed, supraduction and infraduction defects remained and blepharoptosis improved during aduction of the right eye. In the internal ocular motility, miosis in the affected eye. The diagnosis of the aberrant regeneration of the oculomotor nerve after acute palsy was formulated based on anamnesis and ophthalmological follow-up tests.     

Isolated Unilateral Trochlear Nerve Palsy Due to Ipsilateral Dorsal Midbrain Infarction

A 67-year-old Japanese man with essential hypertension and diabetes mellitus abruptly developed isolated right-sided trochlear nerve palsy without pain. Four days later, cranial magnetic resonance imaging demonstrated a tiny ischaemic lesion in the caudal and dorsal midbrain on the right side, which might involve the trochlear fascicles after its decussation. The trochlear nerve palsy resolved within 4 days while treated with intravenous anti-platelet agent. This is a first reported case of isolated unilateral trochlear nerve palsy due to ipsilateral midbrain infarction.     

Spontaneous consecutive Brown syndrome following superior oblique palsy

A 28-year-old female presented with a left trochlear nerve palsy, after indirect head trauma, with no fracture or orbital lesion. She had diplopia, a hypertropia and excyclotropia on right downgaze. Three months later the trochlear palsy had been replaced by Brown's syndrome: a deficit of elevation in adduction, with diplopia, incyclotropia and hypertropia in up-gaze. The Brown syndrome remained the same over a period of 18 months. A 31-year-old male suffered from severe brain contusion with intracerebral haemorrhage and bilateral trochlear nerve palsy. Three years later, he had a bilateral trochlear palsy with bilateral severe Brown's syndrome, with a right hypertropia and 10° to 25° incyclotropia in upgaze and 5° to 10° excyclotropia in downgaze. The field of binocular vision was shifted to left gaze. Orbital CT scan was normal. At surgery, the forced duction test was positive for Brown's syndrome on both sides and the tendon of the superior oblique muscle of the right eye was thickened. The field of binocular vision was centralized after surgery but torsional diplopia in upgaze and downgaze was present as before. Secondary Brown's syndrome after (persisting or vanishing) trochlear nerve palsy without any direct trauma to the superior oblique muscles or the orbit could be caused by a fibrotic reaction of the superior oblique tendon or adjacent structures. This could be due to inactivity or to indirect trauma.     

Vascular compression as a cause of superior oblique myokymia disclosed by thin-slice magnetic resonance imaging

PURPOSE: To describe a case of superior oblique myokymia in which thin-slice magnetic resonance imaging (MRI) appeared to show vascular compression of the trochlear nerve. METHODS: A 50-year-old woman presented with episodic monocular oscillopsia. Neuro-ophthalmologic examinations showed intermittent intorsional microtremor of her right eye, diagnosed as right superior oblique myokymia. Thin-slice (1.6 mm) MRI, using spoiled gradient recalled acquisition in the steady state, was employed to examine the trochlear nerve in its course through the ambient cistern. RESULTS: Imaging disclosed a branch of the posterior cerebral artery immediately adjacent to the right trochlear nerve. CONCLUSION: These magnetic resonance findings suggest that a cause of superior oblique myokymia may be vascular compression of the trunk of the trochlear nerve.     

视神经视网膜炎合并Bell麻痹(英文)

目的:报道1例罕见的视神经视网膜炎合并Bell麻痹。方法:病例报道。结果:男孩16岁,右眼视物模糊1wk就诊,伴高热以及两侧面部不对称。视力右眼0. 1(6/60),左眼1. 0(6/6)。右眼眼底表现为视盘充血水肿及黄斑部存在星芒状皱褶。左侧下运动神经麻痹,Humphrey视野检查表现为旁中心暗点和生理盲点扩大。全血细胞记数显示中性粒细胞增多及血沉加快。血清学检测梅毒、弓形体病、莱姆病、猫抓病阴性。单纯疱疹、带状疱疹、艾滋病毒检测均为阴性。立克次体也为阴性,脑部及眼眶MRI均正常,未发现脱髓鞘病变。起始为甲强龙每日4次250mg静滴3d,出院后继续口服大剂量强的松1mg/kg 11d。6mo后,随访视力达1.0(6/6),视盘略显苍白。Bell麻痹也明显改善,无明显两侧面部不对称。结论:对于视神经炎,临床医生检查其他颅神经有无病变是非常重要的。视神经视网膜炎同时合并面神经麻痹非常罕见,需要进行全面的检查和问诊以排除一些重要的感染性致病原因。视神经炎合并面神经麻痹对大剂量激素治疗敏感。     

视神经视网膜炎合并Bell麻痹

目的：报道1例罕见的视神经视网膜炎合并Bell麻痹。方法：病例报道。结果：男孩16岁，右眼视物模糊1wk就诊，伴高热以及两侧面部不对称。视力右眼0．1（6／60），左眼1．0（6／6）。右眼眼底表现为视盘充血水肿及黄斑部存在星芒状皱褶。左侧下运动神经麻痹，Humphrey视野检查表现为旁中心暗点和生理盲点扩大。全血细胞记数显示中性粒细胞增多及血沉加快。血清学检测梅毒、弓形体病、菜姆病、猫抓病阴性。单纯疱疹、带状疱疹、艾滋病毒检测均为阴性。立克次体也为阴性，脑部及眼眶MRI均正常，未发现脱髓鞘病变。起始为甲强龙每日4次250mg静滴3d，出院后继续口服大剂量强的松1mg／kg 11d。6mo后，随访视力达1．0（6／6），视盘略显苍白。Bell麻痹也明显改善，无明显两侧面部不对称。结论：对于视神经炎，临床医生检查其他颅神经有无病变是非常重要的。视神经视网膜炎同时合并面神经麻痹非常罕见，需要进行全面的检查和问诊以排除一些重要的感染性致病原因。视神经炎合并面神经麻痹对大剂量激素治疗敏感。     

Trochlear nerve palsy as a complication of trigeminal radiofrequency rhyzolysis

We report a patient with right trochlear nerve palsy after percutaneus radiofrequency trigeminal rhizolysis involving the ophthalmic division of the right trigeminal nerve. Of the postoperative complications of percutaneous radiofrequency trigeminal rhizolysis, extraocular nerve injuries are uncommon and the sixth nerve is the frequently affected one. This is a case report of isolated trochlear nerve palsy as a complication of percutaneous radiofrequency trigeminal rhizolysis.     

Schwannoma in patients with isolated unilateral trochlear nerve palsy

PURPOSE: To describe the clinical features of patients with isolated unilateral trochlear nerve palsy secondary to imaging-defined schwannoma of the trochlear nerve. METHODS: A chart review of all patients seen at the Neuro-Ophthalmology Unit at Emory University since 1989. Of 221 patients with trochlear nerve palsy, six had a lesion consistent with a trochlear nerve schwannoma. RESULTS: The six patients had isolated unilateral trochlear nerve palsy. Duration of diplopia before diagnosis averaged 6 months. Magnetic resonance imaging demonstrated circumscribed, enhancing lesions along the cisternal course of the trochlear nerve, all measuring less than 5 mm in greatest dimension. Five of the patients were seen in follow-up, over periods ranging from 11 to 26 months from initial presentation (mean, 15.6 months; standard deviation, 6.0 months). All of these patients remained stable except one, who was slightly worse at 15 months by clinical measurements and magnetic resonance imaging. None of these patients have developed additional symptoms or signs of cranial nerve or central nervous system involvement. CONCLUSIONS: The differential diagnosis of an isolated unilateral fourth cranial nerve palsy should include an intrinsic neoplasm of the trochlear nerve. Magnetic resonance imaging is useful, both for diagnosis and follow-up. These patients can remain stable and may not require neurosurgical intervention.     

先天性上斜肌麻痹患者MRI下滑车神经的影像学表现

目的：明确滑车神经与先天性上斜肌麻痹的关系,进一步揭示上斜肌麻痹的病因,为临床诊断和治疗上斜肌麻痹提供理论依据。 方法：应用3.0T磁共振成像（magnetic resonance imaging,MRI）的3D-CISS序列多平面重组(MPR)结合3D-TOF序列技术分别对16例先天性上斜肌麻痹患者和11例正常人的滑车神经进行显像,通过统计学方法比较两者显影率的差异,判断先天性上斜肌麻痹患者是否合并滑车神经异常。 结果：在3.0T-MRI的3D-CISS序列多平面重组(MPR)结合3D-TOF序列下,先天性上斜肌麻痹患者与正常人的滑车神经脑池段的显影率分别为27.2%和81.2%,两者之间具有统计学差异（P＜0.05）。 结论：先天性上斜肌麻痹与滑车神经异常有关。     

新疆喀什地区脑瘫儿童青少年视觉障碍特征分析

目的：首次全面精准分析新疆喀什地区脑瘫儿童青少年的视觉障碍特征和治疗情况,促进其视觉康 复和全身康复的早期开展。方法：横断面调查研究。选取2018年10月于新疆维吾尔自治区喀什地 区某综合医院集中行眼部筛查的脑瘫儿童青少年,对其进行眼科检查,包括屈光状态、眼位、眼前 节和眼底检查,并调查其眼科治疗情况。采用卡方检验对数据进行分析。结果：纳入176例脑瘫儿 童青少年,年龄0.8～12（6.4±2.7）岁,其中0.8～6岁有97例（55.1%）,维吾尔族169例（96.0%）,男 性104例（59.1%）。存在视觉障碍人数105例（59.7%）,3例（1.7%）同时伴有2种视觉障碍,视觉障碍 的发生率为108例（61.7%）,包括屈光不正（48例,27.3%）、斜视（43例,24.4%）和其他眼部疾病（17 例,9.7%）。所有脑瘫儿童青少年屈光不正以远视为主（20例,11.4%）,斜视以外斜视最常见（25例, 14.2%）,占比最高的前3种其他眼部疾病是视神经萎缩、先天性白内障和先天性青光眼,均为4例 （2.3%）。仅27例（15.3%）脑瘫儿童青少年以往接受过眼科检查,剩余149例（84.7%）均为第1次接受 眼科检查;105例视觉障碍者中仅6例（5.7%）以往接受过眼科检查。所有脑瘫儿童青少年近视发生 率为9.7%（17例）,不同性别、年龄段、民族以及是否斜视之间近视的发生率差异没有统计学意义。 结论：脑瘫儿童青少年视觉障碍发生率高于同年龄段儿童,且斜视发生率非常高。这也提示在脑瘫 儿童青少年中普及眼健康筛查的迫切性和重要性,可作为今后开展脑瘫患者康复工作的重点内容之 一。     

Bilateral ophthalmoplegia during percutaneous transluminal coronary angioplasty

A 61-year-old woman underwent percutaneous transluminal coronary angioplasty (PTCA) to relieve stenosis of the left anterior descending coronary artery. During the procedure ophthalmoplegia with diplopia developed. The diagnosis was partial right third cranial nerve palsy and left fourth cranial nerve palsy. The cause is presumed to have been a microembolic infarct of the right peripheral third nerve coupled with either decompensation of pre-existing left superior oblique palsy or a separate microinfarct of the left trochlear nerve. Over 7 months of follow-up there was partial resolution of the ophthalmoplegia. Ophthalmoplegia during PTCA is rare, and to our knowledge this complication has not been reported in the ophthalmic literature.     

Localization of post-traumatic trochlear nerve palsy associated with hemorrhage at the subarachnoid space by magnetic resonance imaging

PURPOSE: To report evaluation of traumatic trochlear nerve palsy using head magnetic resonance imaging. DESIGN: Observational case reports. METHODS: We examined two cases involving trochlear nerve palsy after closed head injury. RESULTS: Using a fluid attenuated inversion recovery pulse sequence, MRI showed a high-intensity lesion consistent with subarachnoid hemorrhage at the trochlear nerve area in the ambient cisterns. CONCLUSION: An impact force directed toward the tentorium can be a mechanism of injury in some post-traumatic trochlear nerve palsies. Fluid attenuated inversion recovery pulse sequence is a sensitive method for detection of abnormalities in cases associated with head injury.     

Rapid, painless unilateral vision loss in a 37-year-old healthy woman

A 37-year-old woman experienced painless, progressive vision loss to no light perception in the left eye over the course of 3 days. The right eye was unaffected. On examination, the only other abnormal finding was a +4 left afferent pupillary defect. She was initially diagnosed with retrobulbar optic neuritis and admitted for treatment with intravenous methylprednisolone. Neuro-imaging revealed a large right anterior cerebral artery aneurysm that crossed the midline to compress the left optic nerve. The aneurysm was treated with coil embolization, which was technically successful but which did not lead to significant improvement in vision.     

Unilateral congenital oculomotor nerve palsy, optic nerve hypoplasia and pituitary malformation: a preliminary report

A newborn male presented with complete external third nerve palsy of his right eye immediately at birth. Pediatric examination and MRI of the skull revealed no abnormalities. At the age of six weeks, strabismus surgery was performed to facilitate amblyopia treatment. The muscles appeared small and fibrotic. At the age of ten weeks, a brow suspension of the upper lid and a second strabismus surgery were performed. The amblyopia treatment and patching, applied for half of the waking hours over a period of six weeks, were unsuccessful. At the age of six months, a relative pallor of the right optic nerve head became evident. At the age of three years, at a new examination because of growth deficiency, a second MRI revealed defects involving the pituitary region. We concluded that extraocular muscle abnormality or oculomotor nerve palsy was present together with optic nerve dysplasia and pituitary gland malformation.     

Central trochlear palsy

Historically, the trochlear (IV) nerve has been "neglected" by neurologists and ophthalmologists. However, the reported incidence of trochlear palsy in two large series has more than doubled in the past two decades, indicating increasing awareness of this nerve. Trauma is the most common cause of trochlear palsy, as the trochlear nerve is anatomically more vulnerable to trauma than the other ocular motor nerves. Trochlear palsy can also be caused by vascular and inflammatory diseases, congenital factors, toxic substances and tumors. Diplopia secondary to vertical and horizontal deviation is the most common presentation. The trochlear nerve has a relatively high recovery rate after the underlying cause of injury has been corrected. In this article, the anatomy and physiology of the trochlear nerve are described, and the various etiologies, methods of diagnosis and differential diagnosis of trochlear palsy are reviewed.     

Corneal edema induced by cold in trigeminal nerve palsy

We examined a 34-year-old man who complained of decreased visual acuity in the right eye when exposed to cold environmental temperatures. Although examination at room temperature was unremarkable, he developed prominent unilateral corneal edema of the right eye when placed in a cold room at 4 C. Corneal thickness increased from 525 to 789 microns in the affected eye. Further examination disclosed a right-sided trigeminal nerve palsy. He was eventually found to have a 3 X 2-cm tentorial ridge meningioma on the right.     

Blindness associated with enlarging mycotic aneurysm after cavernous sinus thrombosis

PURPOSE: We report a patient with an enlarging internal carotid mycotic aneurysm secondary to septic cavernous sinus thrombosis presenting with acute visual loss. DESIGN: Single observational case report. METHODS: Retrospective review of the medical record and review of the literature. RESULTS: A 19-year-old man with residual left sixth nerve palsy and decreased vision in his left eye caused by left cavernous sinus thrombosis secondary to pansinusitis was seen 2 weeks after discharge with acute decreased visual acuity in the right eye. A workup revealed an enlarging left carotid/ophthalmic aneurysm that compressed the optic chiasm and right optic nerve. The patient was taken to the interventional angiography suite, where his left internal carotid artery was occluded endovascularly. The patient's vision improved on discharge. CONCLUSIONS: Visual loss caused by a mycotic carotid aneurysm is an infrequent sequelae after cavernous sinus thrombosis and is not well described in the literature. To our knowledge, this is the first reported case of acute visual loss associated with a mycotic ophthalmic aneurysm. The result of treatment was good in this case, with the patient's visual acuity returning to pretreatment status.     

头颅外伤患者的眼运动神经麻痹(英文)

目的:了解头颅外伤患者眼运动神经麻痹的情况。方法:收集2006-03/2006-09 Shahid Rahnemon医院神经外科收治的300名头颅外伤患者的资料,包括眼科检查和调查问答,采用SPSS软件卡方和F检验进行数据分析。结果:300例患者中242例为男性(81. 1% ), 58例为女性(18.9% ),年龄为1~87(平均46)岁。意外跌伤是头部外伤最常见的原因,共247例患者(82. 3% )因此致伤;大多数患者的GCS得分为13~15(82.3% )。最多见的颅脑外伤为硬膜下腔、蛛网膜下腔出血。滑车神经或外展神经麻痹(28.6% )、其他眼运动神经麻痹或同时两处眼运动神经麻痹(常见第3颅神经和第4颅神经麻痹,14.3% )是最常出现的情况。结论:虽然头颅外伤同时出现颅神经麻痹的几率较小,但是在急诊时应根据情况进行神经眼科检查。     

Isolated trochlear nerve palsy secondary to a juvenile pilocytic astrocytoma

A 9-year-old female developed a fourth nerve palsy which was the first sign of a posterior fossa astrocytoma. The fourth nerve palsy was believed to have resulted from direct invasion of the trochlear nerve rather than compression by hydrocephalus. Sagittal reconstruction of a computed tomogram revealed extension of the tumor into the dorsal midbrain where the trochlear nerve exits.     

Acquired, isolated third nerve palsies in infants with cerebrovascular malformations

PURPOSE: To report two infants with acquired, isolated third nerve palsies attributable to intracranial cerebrovascular malformations. DESIGN: Observational case report. METHODS: Two patients are described. Each was examined in a university-based pediatric ophthalmology and neuro-ophthalmology practice. RESULTS: An 8-month-old child presented with a pupil-involving partial left third nerve palsy because of a partially thrombosed fusiform aneurysm of the left internal carotid artery. A 3-month-old infant developed a right third nerve palsy from a giant arteriovenous fistula arising from an M2 branch of the right middle cerebral artery. CONCLUSION: Patients younger than 8 months and 3 months with acquired, isolated third nerve palsies resulting from intracranial cerebrovascular malformations could not be found in a MEDLINE search. In conclusion, at even this young age, acquired, isolated third nerve palsies may be the initial manifestation of an intracranial aneurysm or fistula. Magnetic resonance imaging (MRI) and MRI-angiography were adequate for detecting these processes.