Two birds, one stone: a surgical approach for third nerve palsy with aberrant regeneration / Tratamento cirúrgico de paralisia de terceiro nervo craniano com regeneração aberrante

ABSTRACT Aberrant regeneration in third nerve palsies, linking medial rectus contraction to the levator palpebrae muscle, is a great opportunity for surgical planning to address both the ptosis and horizontal deviation in a single procedure. We report a case of severe ptosis associated with exotropia that was successfully corrected with a single horizontal strabismus surgery owing to aberrant regeneration and discuss the basis underlying the surgical planning.

RESUMO A regeneração aberrante nas paralisias do terceiro nervo, ligando a contração do reto medial ao músculo levantador da pálpebra, é uma grande oportunidade para fazer um planejamento cirúrgico para tratar tanto a ptose quanto o desvio horizontal em um procedimento único. Relatamos uma ptose grave associada à exotropia corrigida com sucesso com uma única cirurgia de estrabismo horizontal devido à regeneração aberrante e discutimos as bases do planejamento cirúrgico.

Oculomotor nerve palsy associated with internal carotid artery: case reports

Oculomotor nerve palsy limits the specific direction eyeball movement, and represents diplopia, mydriasis, and ptosis. The vascular-associated etiologies of oculomotor nerve palsy are the microvascular ischemia due to hypertension or diabetes, or compression of the nerve by the aneurysm. For the aneurysm, if not treated properly, it may result in mortality or severe neurological impairment. Thorough history taking, physical examinations, and proper imaging modality are needed to make an accurate diagnosis. A 76-year-old female with decreased mentality and anisocoria presented at our emergency department. An 83-year-old female presented with right ptosis and lateral-side deviated of the right eyeball. No definite lesion was noted on the initial non-contrast brain computed tomography (CT) and magnetic resonance imaging diffusion. An aneurysm was detected on CT angiography taken several hours later in the former patient. For the latter patient, a giant aneurysm was detected on magnetic resonance angiography that had been performed at another hospital 4 days earlier. These two patients underwent transfemoral cerebral angiography with coiling. They were discharged with no neurological sequelae.

A Successful Stent-Assisted Coil Embolization in a Patient with Oculomotor Palsy Due to Partially Thrombosed-Aneurysm in Cavernous Internal Carotid Artery

No abstract available.

Prognostic influencing factors of posterior communicating aneurysm associated with oculomotor nerve palsy / 中国医师进修杂志

Objective To investigate the prognosis of patients with posterior communicating aneurysm associated with oculomotor nerve palsy in 12 months, and analyze the possible prognostic influencing factors.Methods A prospective clinical study was conducted in 39 patients with posterior communicating aneurysm associated with oculomotor palsy.The patients were followed up for 12 months after surgery,and the prognosis of oculomotor palsy symptoms was evaluated.Results In 39 patients,16 cases were treated by craniotomy clipping, and 23 cases were treated by intravascular embolization. Univariate Logistic analysis result showed that the prognosis of oculomotor palsy symptoms in patient with age ≤ 60 years was significantly better than that in patient with age >60 years, the prognosis of the patients with operation timing≤14 d was significantly better than that of patients with operation timing>14 d, and there were statistical differences (P<0.05 or <0.01); the aneurysm hemorrhage, aneurysm orientation, aneurysm size, surgical procedure and preoperative oculomotor nerve palsy degree were unrelated to the prognosis of oculomotor palsy symptoms (P>0.05). Multifactor Logistic analysis result showed that age and operation timing were the independent prognostic influencing factors of oculomotor palsy symptoms(OR=6.574 and 32.510,95% CI 1.119-38.640 and 2.869-368.363,P<0.05 or<0.01). Conclusions Surgical treatment of aneurysms can improve the prognosis in patients with posterior communicating aneurysm associated with oculomotor nerve palsy,and the prognosis of patients with young age and early surgical treatment is relatively better.

Clinical features of unilateral oculomotor nerve palsy related to multiple myeloma:a case report and literature review / 中华全科医师杂志

Objective To analyze the clinical features of unilateral oculomotor nerve palsy caused by multiple myeloma(MM).Methods A 79-year-old female diagnosed MM for 3 years was admitted due to the disease relapse.The patient presented left oculomotor nerve palsy,bone marrow biopsy showed 4.5％ of myeloma cells,the serum level of λ light chain was up to 18 g/L,and brain CT/MRI scan revealed left parasphenoidsinus lesion.A diagnosis of relapsing intramedullary and extramedullary MM,IgGλ type,stage ⅢA was made.Ten cases were retrieved from literature since 1990,the clinical features of 11 cases were analyzed as follows.Results Among 11 cases of unilateral oculomotor nerve palsy caused by MM,7 were males and 4 females with a mean age of (60 ± 12) years (40-79 years).The sub-types of MM were IgG type (7 cases),IgA type (2 cases),biclonal of IgG and IgA type (1 case),and IgD type (1 case).Oculomotor nerve palsy was presented as the initial manifestation of MM in 9 cases,as a sign of relapse of MM in 1 case,and during MM treatment in 1 case.In 7 cases,oculomotor nerve was the only cranial nerve involved,while in other 4 cases,the Ⅳ,Ⅴ,Ⅵ cranial nerves were also involved.Neuroimaging revealed parasphenoid sinus lesions in 9 cases,and myeloma meningitis in 2 cases.Most of the reviewed cases achieved significant clinical improvement after chemotherapy and/or radiotherapy,except 2 cases with myeloma meningitis.The case in our department was improved significantly and rapidly after receiving chemotherapy with bortezomib.Conclusion MM should be considered when unilateral oculomotor nerve palsy is presented with or without the history of MM,the disease is sensitive to chemotherapy in most circumstances.

The analysis of influence factor on the recovery time of oculomotor nerve palsy after traumatic carotid-cavernous sinus fistula treated by balloon embolization / 中国医师进修杂志

Objective To investigate the influence factor of the recovery time of oculomotor nerve palsy (ONP) after traumatic carotid-cavernous sinus fistula (TCCF) treated by balloon embolization.Methods The clinical data of 76 patients with ONP after TCCF were retrospectively analyzed.All patients accepted intravascular balloon embolization treatment.Nonparametric test was applied to make single factor analysis of the influence factor of ONP recovery time,and linear regression analysis was applied to make multiple factor analysis.Results Seventy-six patients (100.0％) had a perfect occlusion for orificium fistulae after operation immediately,and 73 patients (96.1％) retained the internal carotid artery.Patients were followed up for 6-70 months,with an average of 34.2 months and no death cases.Seventy patients (92.1％) succeeded for embolization at the first time,and 6 patients (7.9％) relapsed after embolization for 6 weeks.The reasons of relapse was balloon leak,and no patients recurred after twice embolization.Seventy-six patients (100.0％) had recovery from ONP,and recovery time was (42.17 ± 32.39) d.The single factor analysis showed that the courses of diseases,fistula location,eye-tubercle location,degree of ONP,balloon quantity,state of internal carotid artery were the factor affecting the ONP recovery time (P ＜ 0.01 or ＜ 0.05).The linear regression analysis showed that the courses of the disease,fistula location,degree of ONP,balloon quantity were independent factor affecting the ONP recovery time (P ＜ 0.01).Conclusions Intravascular balloon embolization in the treatment of ONP after TCCF is safe and reliable.The courses of diseases,fistula location,degree of ONP and balloon quantity are the influencing factor of the oculomotor nerve functional recovery time,and should be given enough attention.

Clinical analysis of neuro-ophthalmological features in 45 patients with intracranial aneurysm / 中华眼底病杂志

Objective To observe the neuro-ophthalmological features of intracranial aneurysm.Methods 169 patients with intracranial aneurysm were retrospectively studied.45 patients, including 18 men and 27 women, had neuro ophthalmological symptoms or signs.Their average age was (56.21 ± 16.11) years and 32 (71.11％)patients' age was more than 50 years.The onset time ranged from 30 minutes to 20 years.20 (44.44％) patients' onset time was among 24 hours.CT, CT angiography, MRI, MRI angiography and cerebral digital subtraction angiography were performed alone or combined in all 45 patients.Visual acuity, pupil reflex and eye movement were examined.Clinical data including general condition, initial symptoms, neuro-ophthalmological changes, imaging data and treatment effects were recorded.Results 26.63％ of the 169 patients had neuro-ophthalmological symptoms or signs.There were 6 patients (13.33％) with neuro ophthalmological changes as their first manifestation and 39 patients (86.67 ％) with neurologic changes as first manifestation.Neuro-ophthalmological symptoms included vision loss (10 patients, 22.22％), diplopia (4 patients, 8.89％) and ocular pain (2 patients, 4.44％).The most common neuro-ophthalmological sign was pupil abnormality which was found in 31 patients (68.89 ％).The second most common sign was eye movement disorder (16 patients, 35.56％).The other signs included ptosis (8 patients, 17.78％), nystagmus (2 patients, 4.44％), exophthalmos (1 patient, 2.22％) and disappeared corneal reflection (1 patient, 2.22％).Imaging examination indicated that intracranial hemorrhage happened in 29 patients (64.44％).The most common neuro-ophthalmological features were pupil abnormality, eye movement disorder and vision loss in both patients with or without intracranial hemorrhage.The incidence of pupil abnormality was higher in patients with intracranial hemorrhage than that without intracranial hemorrhage, the difference was statistically significant (x2=7.321, P=0.007).Pupil abnormality and vision loss were common in patients with internal carotid artery aneurysm, and eye movement disorder was common in patients with internal carotid artery aneurysm and posterior communicating aneurysms.Conclusions Patients with intracranial aneurysm have different neuroophthalmological features.The most common features are pupil abnormality, eye movement disorder and vision loss.

Paralisia do nervo oculomotor como manifestação inicial de hematoma subdural crônico ? Relato de caso / Oculomotor nerve palsy as initial manifestation of chronic subdural hematoma ? Case report

A presença de paralisia do nervo oculomotor (NOM) sem outro déficit neurológico é considerada rara como forma de apresentação em hematoma subdural crônico (HSDC). Geralmente apresenta sintomas de déficit neurológico focal, cefaleia e alterações do nível de consciência, havendo múltiplos diagnósticos diferenciais. RTA, 79 anos, masculino. Paciente com demência senil, hipertensão arterial sistêmica e diabetes mellitus. Estado geral: moderado. Exame físico: sonolento, eupneico. Exame neurológico: disfásico e anisocoria esquerda. Tomografia computadorizada (TC) de crânio sem contraste revelou lesão com densidade heterogênea na região frontoparietotemporal esquerda com efeito de massa e hipodensa na região frontoparietal direita. Submetido a trépano-punção frontal anterior e parietal posterior esquerda e drenagem do hematoma. Evoluiu com melhora da paralisia do NOM à esquerda. Em caso de HSDC volumoso, pode-se comprimir o mesencéfalo e apresentar-se herniação do uncus do hipocampo, podendo causar paralisia do NOM. Seu diagnóstico precoce e tratamento correto apresentam bons resultados...

The presence of complete paralysis of the oculomotor nerve (OMN) with no other neurological deficit is rare as the presentation of chronic subdural hematoma (CSDH). Usually there are symptoms of focal neurologic deficit, headache and changing consciousness level, so there are multiple differential diagnoses. RTA, 79-year-old man. Patient who has senile dementia, hypertension and diabetes mellitus. General condition: moderate. Physical examination: sleepy, eupneic. Neurological examination: dysphasia and anisocoria left eye. Computed tomography (CT) scan without contrast revealed a lesion with heterogeneous density in the left frontoparietotemporal region, with mass effect and hipodense region right parietofrontal. The patient was submited to trepano-punction at left anterior frontal and posterior parietal and drainage of the hematoma. He evolved with neurological improvement of the paralysis of OMN on the left eye. The CSDH when it was large, can compress the midbrain and provide herniation of hippocampus? uncus may cause paralysis of the OMN. Early diagnosis and correct treatment has shown good results...

Management of Severe Bilateral Ptosis in a Patient With Midbrain Infarction: A Case Report

Ptosis could be caused by oculomotor nerve palsy in the midbrain infarction. Bilateral ptosis has been reported in several reports, which focused on clinical characteristics of midbrain infarction. Little research attention has been paid to the treatment of patients with bilateral ptosis in midbrain infarction. We experienced a case of severe bilateral ptosis occurring after midbrain infarction. The patient could not open her eyes, perform basic activities or achieve effective rehabilitation. Neurogenic ptosis can improved after the underlying cause is treated. However, in this case, bilateral ptosis was not improved after conservative care for 6 months and the patient remained limited in activities of daily living and mobility. Surgical correction of bilateral ptosis was done by the resection of both Muller's muscles. After surgical correction, the bilateral ptosis was much improved and the effect persisted for at least 6 months.