Pediatric ocular motor cranial nerve palsy: Demographics and etiological profile

Purpose:The aim of this study was to describe epidemiological and clinical characteristics of pediatric ocular motor cranial nerve palsy.Methods:This was a retrospective record-based study, carried out at a tertiary eye care hospital in India, between January 2011 and January 2015 and included patients up to 16 years of age at the time of presentation, diagnosed with third, fourth, sixth nerve palsy or a combination of these with other cranial nerve palsy. Data analyzed included demographic details, etiologies, presence or absence of amblyopia, relevant investigations, and management.Results:A total of 90 cases were included in the study. Eighty patients (88.88%) presented with isolated nerve palsy. Forty-three patients (47.77%) had congenital nerve palsy. The most common nerve involved was third (n = 35, 38.88%) followed by sixth (n = 23, 25.55%) and fourth nerve (n = 22, 24.44%). Most common cause of third and fourth cranial nerve palsy was congenital (n = 18, 51.42% and n = 17, 77.30%, respectively), while it was trauma for the sixth nerve (n = 7, 30.40%). Amblyopia was most frequently associated with third cranial nerve palsy (n = 27, 77.14%). The radio-imaging yield was maximum (n = 7, 70%) for combined cranial nerve palsy. Overall 44 (48.88%) patients were managed conservatively, while 46 (51.11%) patients needed squint with or without ptosis surgery.Conclusion:The most common ocular motor cranial nerve involved in the pediatric population was the third cranial nerve, and it was found to be the most amblyogenic in this age group. The neuroimaging yield was maximum for combined cranial nerve palsy. The most common conservatively managed nerve palsy in this study group was the fourth nerve palsy.     

Chronic isolated trochlear nerve palsy produced by intracavernous internal carotid artery aneurysm. Report of a case.

The fourth cranial nerve is rarely affected by intracranial aneurysms, and when this occurs other motor ocular nerves and the trigeminal nerve are almost always involved as well. In the case reported, a middle-aged woman presented with a long-standing selective and stationary palsy of the right superior oblique muscle. Neuroradiologic studies disclosed an aneurysm arising at the C-3 segment of the right internal carotid artery.     

颅底动脉瘤的眼部改变

目的：探讨颅底动脉瘤的早期眼部改变，避免误诊。方法：回顾性对30例颅底动脉瘤的眼部改变进行分析。结果：临床表现有4组：①单纯颅神经受压症状6例。②自发性颈动脉海绵窦瘘5例。③轻度蛛网膜下腔出血伴有颅神经受压症状6例。④蛛网膜下腔出血为主者4例。总计颅神经受压症状中，动眼神经麻痹16只眼(53％)，外展神经麻痹11只眼(37％)，三叉神经麻痹11只眼(37％)，视神经受损导致的视力减退9只眼(30％)。视神经萎缩5只眼(17％)，视乳头水肿2只眼(7％)。结论：中年以上原因不明的明显头痛伴有动眼神经等颅神经障碍者，自发性颈动脉海绵窦瘘者应警惕到颅底动脉瘤的可能。     

Computed Tomography Angiography of Bilateral Intracavernous Internal Carotid Artery Aneurysms

Bilateral intracavernous internal carotid artery aneurysms are rare. They are more common in elderly females and are associated with hypertension. We present the computed tomography angiography findings of an 81-year-old female with history of hypertension who came complaining of diplopia and headache. Examination revealed bilateral sixth nerve palsy with left third nerve palsy. External ocular examination was normal. Computed tomography angiography was done and revealed bilateral intracavernous internal carotid artery aneurysms. She was referred to neurosurgery for further management.     

Cause and prognosis of neurologically isolated third, fourth, or sixth cranial nerve dysfunction in cases of oculomotor palsy

Purpose To determine the cause and prognosis of neurologically isolated third, fourth, or sixth cranial nerve dysfunction in cases of oculomotor palsy, and to determine the best imaging methods to make a correct diagnosis. Methods The medical records of 221 consecutive patients with oculomotor palsy caused by neurologically isolated cranial nerve dysfunction were reviewed. There were 63 cases of third, 41 of fourth, and 117 of sixth cranial nerve dysfunction. The patients were examined at the Neuro-ophthalmology Clinic of Kyoto University Hospital between 1993 and 2001. Results Vascular disorders accounted for 34.9% of the third nerve dysfunction, and 90% of these recovered completely in 6 months. Ninety percent of the patients with an isolated third nerve dysfunction that was caused by an aneurysm also had anisocoria, and 68% of the patients with a third nerve dysfunction caused by a vascular disorder had anisocoria. In all of the vascular cases with anisocoria, the difference in the pupillary diameter was <1.0 mm. The presence of ptosis did not play an important role in making a diagnosis of third nerve dysfunction. Ninety percent of the patients with fourth nerve dysfunction and 60% of the patients with sixth nerve dysfunction recovered within 9 months. Conclusions The age of the patient, signs of an improvement, and associated alterations are important diagnostic markers to determine the best type of imaging methods for evaluating neurologically isolated third, fourth, and sixth cranial nerve dysfunction.     

One-Sided Headache Is a Symptom Suggesting Aneurysmal Lesion in Patients with Isolated Abducens Nerve Palsy

An isolated unilateral abducens nerve palsy or headache alone usually yields negative findings on neuroimages. The authors report an individual with right abducens nerve palsy who developed a sudden, persistent headache on the right side. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) revealed a giant aneurysm of the cavernous carotid artery that was located along the course of the right abducens nerve. The findings in this case of isolated abducens nerve palsy suggest that headaches should be considered as important signs for intracranial aneurysmal lesions.     

Pupil sparing incomplete third nerve palsy secondary to a cavernous sinus meningioma: challenges in management

Background: The diagnosis of incomplete third nerve palsy can be clinically challenging because the aetiologies, as well as presentations, can be variable and subtle. The optometric clinician should be familiar with the association of third nerve palsy with compressive lesions, including the clinical presentations and management of these patients. Case report: We present a 68‐year‐old hypertensive male complaining of intermittent diplopia for the previous six months. Neurological examination revealed a mild deficit in adduction, reduced range of vertical motility and questionable ptosis, all limited to the OD. No pupillary involvement was noted. MRI revealed a cavernous sinus meningioma. The patient elected against surgery, choosing MRI every six months. Conclusion: Due to the subtle clinical presentation of incomplete pupil sparing third nerve palsy, this ophthalmoplegia may be easily overlooked. The associated aetiologies of palsy of cranial nerve three (CN3) carry increased risk of morbidity and mortality. Management should include evaluation for mass lesions and/or vascular aetiologies, regardless of pupillary involvement.     

Third nerve palsy due to cerebral artery aneurysm in a child

We report a case of cerebral aneurysm in a seven-year-old girl who presented with subacutely progressive third nerve palsy. To our knowledge this is the youngest reported patient with this condition. Confusion with myasthenia gravis occurred because of improvement in the patient's ptosis after intravenous edrophonium chloride. Cerebral CT revealed a hyperdense mass that was characterised on cerebral angiography as an aneurysm of the posterior communicating artery. Another occult aneurysm of the posterior cerebral artery was found at surgery. This case demonstrates that third nerve palsy due to cerebral aneurysm may affect patients at a younger age than has previously been recognised. Therefore we suggest that even young children should have aneurysm excluded by cerebral CT and angiography if they present with acquired third nerve palsy involving the pupil. In addition this case highlights the false-positive results that may occur with the edrophonium chloride test for myasthenia gravis.     

神经眼科急症的诊断和治疗

神经眼科急症是指如果不及时诊治,就会严重威胁视力或生命的眼科临床病症,主要表现为急性视力下降、突发的复视和瞳孔不等大。一些危重神经系统疾病和眶颅炎症早期常以神经眼科急症作为首发表现。视神经炎、动脉炎性前部缺血性视神经病变、严重的眼眶炎症和感染、垂体卒中等疾病早期常出现急性视力下降;海绵窦血栓和颅内动脉瘤早期因累及颅神经...     

123例单纯性动眼神经麻痹的MRI病因学分析

目的 探讨单纯性动眼神经麻痹的MRI表现及病因。设计 回顾性病例系列。研究对象123例单纯性动眼神经麻痹患者。方法 回顾性分析患者的MRI表现,结合动眼神经的解剖特点,分析动眼神经麻痹的病因。主要指标  MRI表现。结果 123例动眼神经麻痹病例中,MRI表现异常者87例（70.7%）。其中海绵窦区病变62例（71.2%）（炎症45例,颈内动脉动脉瘤8例,鼻咽部/蝶窦/鞍区/鞍旁占位性病变累及海绵窦者6例,颈内动脉海绵窦瘘2例,颈内动脉海绵窦段增粗迂曲1例）;脑干病变16例（18.4%）（中脑梗塞15例,中脑炎症1例）;颅眶沟通性病变5例（5.7%）（炎症3例,肿瘤2例）;动眼神经脑池段及其周围病变4例（4.6%）（动眼神经炎性病变2例,动眼神经神经鞘瘤1例,脚间池胆脂瘤压迫动眼神经1例）。结论 单纯性动眼神经麻痹的病因多样,海绵窦区病变占大多数。MRI检查有助于明确动眼神经麻痹的病因。（眼科, 2015, 24： 304-308）     

Isolated Pupil-Involving Third Nerve Palsy as the First Presentation of Sarcoidosis

Neurosarcoidosis is seen in 5–15% of patients with systemic sarcoidosis. The most common cranial nerve presentations are optic neuropathy and facial nerve palsy. The authors present a case of sarcoidosis presenting with a pupil-involving third nerve palsy. The patient responded to corticosteroid therapy with resolution of investigations her cranial nerve palsy but progressed to develop cerebellar signs. This is the first documented case of a pupil-involving third nerve palsy occurring as the first presentation of neurosarcoidosis. Although typically a pupil-involving third nerve palsy necessitates urgent neuroimaging to rule out a posterior communicating artery aneurysm, it is important to recognise inflammatory causes in the differential diagnosis.     

Fourth Nerve Paresis and Ipsilateral Horner’s Syndrome: An Unusual Association

Presence of a fourth nerve palsy and ipsilateral Horner’s Syndrome (HS) is an exceptional association. A case of a 54 year-old patient with diplopia due to a fourth nerve palsy and acquired HS on the same is presented along with magnetic resonance images (MRI) revealing a mass in the right cavernous sinus. This new combination of ipsilateral signs is analyzed.     

Isolated Pupil-Involving Third Nerve Palsy as the First Presentation of Sarcoidosis

Abstract

Neurosarcoidosis is seen in 5–15% of patients with systemic sarcoidosis. The most common cranial nerve presentations are optic neuropathy and facial nerve palsy. The authors present a case of sarcoidosis presenting with a pupil-involving third nerve palsy. The patient responded to corticosteroid therapy with resolution of investigations her cranial nerve palsy but progressed to develop cerebellar signs. This is the first documented case of a pupil-involving third nerve palsy occurring as the first presentation of neurosarcoidosis. Although typically a pupil-involving third nerve palsy necessitates urgent neuroimaging to rule out a posterior communicating artery aneurysm, it is important to recognise inflammatory causes in the differential diagnosis.     

The role of botulinurn toxin in third nerve palsy

Isolated third nerve paresis is a rare diagnosis among patients presenting to the Botulinum Toxin Clinic at Moorfields Eye Hospital. Ten patients with this diagnosis are reviewed in this study. Head trauma is a common cause of third nerve palsy and is often severe enough to cause damage to fusion potential. If fusion is present and there is adequate adduction of the divergent eye, then botulinum toxin injection of the lateral rectus may induce long-term control of the ocular deviation. Three of the four patients who experienced tong-term control of their ocular deviation following toxin injection shared these features. Toxin injected into the lateral rectus did not, however, reliably assess medial rectus function and therefore predict the outcome of horizontal squint surgery. Reasons for this are discussed.     

伴眼部表现的颈内动脉动脉瘤的临床分析

目的 分析伴眼部表现的颈内动脉动脉瘤(AICA)的部位、大小及眼部表现临床特点.方法 回顾性分析2001年12月至2009年6月于解放军总医院眼科就诊的42例AICA患者的临床资料,分析伴眼部表现的AICA发生部位、大小及眼部表现临床特点.结果 42例伴眼部表现的AICA患者中,发生于床突旁23例,巨大动脉瘤23例,眼部主要表现分别为患侧眼视力显著下降25例、动眼神经麻痹21例、展神经麻痹7例及不同程度视野改变.结论 AICA眼部表现主要为患侧眼视力显著下降、不同程度视野缺损、动眼神经麻痹、展神经麻痹等.伴眼部表现的AICA以床突旁为主,多为巨大动脉瘤.     

Prevalence of ocular motor cranial nerve palsy and associations following stroke

Aim

Occurrence of ocular motor cranial nerve palsies (OMCNP), following stroke, has not been reported in relation to the type of OMCNP seen and in relation to brain area affected by stroke. The aim of this study was to identify all patients referred with suspected visual impairment to establish the presence and type of OMCNP.

Methods

Prospective, observation study with standardised referral and assessment forms across 20 sites. Visual assessment included visual acuity measurement, visual field assessment, ocular alignment, and movement and visual inattention assessment. Multicentre ethics approval and informed patient consent was obtained.

Results

In total, 915 patients were recruited with mean age of 69.18 years (SD 14.19). Altogether, 498 patients (54%) were diagnosed with ocular motility abnormalities. Of these, 89 patients (18%) had OMCNP. Unilateral third nerve palsy was present in 23 patients (26%), fourth nerve palsy in 14 patients (16%), and sixth nerve palsy in 52 patients (58%). Out of these, 44 patients had isolated OMCNP and 45 had OMCNP combined with other ocular motility abnormalities. Location of stroke was reported mainly in cerebellum, brain stem, thalamus, and internal and external capsules. Treatment was provided for each case including prisms, occlusion, typoscope, scanning exercises, and refraction.

Conclusions

OMCNP account for 18% of eye movement abnormalities in this stroke sub-population. Sixth CNP was most common, followed by third and fourth CNP. Half were isolated and half combined with other eye movement abnormality. Most were treated with prisms or occlusion. The reported brain area affected by stroke was typically the cerebellum, brain stem, and diencephalic structures.     

Encephalopathy,Chiasmal Compression,Ophthalmoplegia, and Diabetes Insipidus in Pituitary Apoplexy

ABSTRACT

Pituitary apoplexy with haemorrhage is a potentially life-threatening condition, and a rare cause of third nerve palsies. The range of vision loss and ophthalmoplegia seen in cases of apoplexy reflects the variability of cranial structures compressed by mass effect. The pathophysiology of extraocular muscle limitation and facial paraesthesia occurs with compression of the cavernous sinus, which contains cranial nerves III, IV, VI, and the ophthalmic branch of V. Blood supply to adjacent structures may be also compromised, causing additional loss of function. This case report of a patient with diabetes insipidus and a third nerve palsy illustrates the anatomic basis of the presenting signs of pituitary apoplexy, and the necessity for prompt neuroimaging if it is suspected.     

直接外伤性颈动脉海绵窦瘘1例

一位14岁的马来男童发生车祸,身体多处受伤。患者因眶周血肿转交眼科,眼部检查正常,但发现右眼眼球突出,后来伴随眼压(intraocular pressure,IOP)增加。经血管造影诊断为直接型颈动脉海绵窦瘘(carotid cavernous sinus fistula,CCF)并给予栓塞治疗。     

Ocular manifestations of internal carotid artery dissection

Internal carotid artery dissection (ICAD) results from disruption of the intima of the arterial wall, and can lead to intrusion of blood into the arterial wall and form an intramural hematoma. The hematoma can compress the true lumen of the vessel, causing functional stenosis or occlusion. The classic triad signs of ICAD include pain in the ipsilateral neck, head and orbital regions; a (partial) Horner syndrome; and cerebral or retinal ischemia. However, not all ICAD patients present with this classic signs. In some cases, ocular manifestations are the initial (and sometimes the only) findings. We summarize the ocular manifestations associated with ICAD in 3 categories: visual symptoms, oculosympathetic palsy, and ocular motor nerve palsy.     

Acute Transient Oculomotor Nerve Palsy from Presumed Cavernous Angioma in an Infant

Cavernous angiomas of the cranial nerves are extremely rare, and those of the oculomotor (third) cranial nerve are rarer still, with no previous cases having been reported in the literature. We report herein the first case of a presumed cavernous angioma involving the subarachnoid portion of the left third nerve presenting as an acute left third nerve palsy in an infant. The child was followed without intervention and the palsy completely resolved. Given the poor functional results with attempted surgical excision and the potential for spontaneous improvement in oculomotor nerve function, it is reasonable to follow patients with these lesions without intervention.