Regeneración aberrante del III nervio craneal por aneurisma cerebral bilateral. Reporte de caso / Aberrant regeneration of the III cranial nerve due to bilateral cerebral aneurism

RESUMEN Los trastornos de la motilidad ocular constituyen motivo de consulta periódica en Oftalmología. La regeneración aberrante, trastorno muy poco reportado, es considerada la sincinesia oculomotora de mayor invalidez y complejidad. Diversas condiciones neuroftalmológicas están implicadas en la etiopatogenia de la enfermedad, la mayoría de las cuales puede ocasionar la muerte. El manejo de los síntomas y signos provocados por paradójicos movimientos oculares conjugados es difícil. Se reportó un caso con remisión tardía a neuroftalmología por diagnóstico inicial y evolución desfavorable. La historia psicofísica arrojó diagnóstico definitivo de regeneración aberrante del III nervio craneal secundario, a aneurisma cerebral de la carótida interna bilateral, agravado por reanastomosis quirúrgica. Una rigurosa, obligatoria e impostergable historia neuroftalmológica, se impone ante toda parálisis del III nervio craneal para brindar un diagnóstico etiológico preciso y de esta forma proteger la vida.

ABSTRACT The disturbances in ocular motility are the cause of periodical consultation in Ophthalmology. The aberrant regeneration, a scarcely reported disturbance, is considered the oculomotor synkinesis of highest disability and complexness. Several neuro-ophthalmologic conditions are implicated in the disease ethiopathogeny, and most of them could lead to death. The management of the symptoms and signs caused by paradoxical conjugated ocular movements is difficult. A case is reported of late remission to Neuro-ophthalmology due to unfavorable diagnosis and evolution. The psycho-physical history led to a definitive diagnosis of aberrant regeneration of the III secondary cranial nerve, to cerebral aneurism of the bilateral internal carotid, worsened by surgical re-anastomosis. In front of any paralysis of the III cranial nerve, it is necessary a rigorous, obligatory and immediate neuro-ophthalmological history to arrive to a precise etiological diagnosis, protecting life in that way.

Sinquinesis óculomotora: dos casos de pacientes excepcionales / Oculomotor synkinesis: two cases excepcional patients

Las sinquinesis son movimientos simultáneos o coordinados en secuencia de mivimientos de músculos suplidos por diferentes nervios o por ramas independientes del mismo nervio que ocurren luego de la recuperación de una lesión axonal periferica; son debidos a la dirección errónea ("misdirection") que toman algunos axones hacia otros músculos que no constituyen su objetivo o blanco; así, cuando el paciente intenta mover algunos músculos, ocurren contracciones involuntarias en otros, no esperadas anatómicamente. Es una suerte de recableado mal realizado y confuso. En las dos pacientes que constituyen nuestro informe, ocurrieron alteraciones óculomotoras excepcionales. En la primera de 60 años portadora de un aneurisma gigante del senocavernoso izquierdo, la sinquinesis nerviosa aberrante ocurrió entre los nervios craneales tercero y sexto. En la segunda de 22 años a quien se resecó un osteocondroma gigante de la fosa media derecha, desarrolló una parálisis total del tercer nerviocraneal con sinquinesis trigémino-oculomotora entre el músculo pterigoideo derecho y el elevador del párpado superior; así como también entre el tercero (recto inferior) y sexto nervios (recto externo) ipsolateral. Se revisa la literatura al respecto.

Synkinesis are simultaneous or coordinated sequential movements of muscles that are supplied by different nerves or have independent nerve branches. They occur after the recovery a peripheral axonal injury. They are due to axons taking a wrong direction ("misdirection") towards muscles that do not constitute their objetives or targets. Thus, when the patient attempts to move a muscle, other muscles show anatomically unexpected involuntary contractions. It is a sort of confusing rewiring. Our report is based on the exceptional oculomotor alterations that occurred in two patients. In the first patient, a 60 years-old female carrying a giant aneurysm of the left cavernous sinus, the aberrant nerve synkinesis ocurred between the third and sixth cranial nerves. In the second patient, a 22 year-old female to whom was resected a giant osteochondroma of the right middle fossa, developed a total paralysis of the third cranial nerve with trigeminal oculomotor synkinesis between the right pterygoid muscle and the elevator of the upper eyelid; as well as between the inferior rectus and ipsilateral external rectus. We review the literature on the subject.

<b>The Effectiveness of Acupuncture for Crocodile Tears Syndrome </b> / 日本東洋医学雑誌

I treated crocodile tears syndrome (gustatory-lacrimal reflex) after right facial nerve palsy with acupuncture. The patient was a 74-year-old female. Her right peripheral facial nerve palsy had started one and a half years earlier.<br>Most of her facial nerve palsy symptoms disappeared in about 5 months. Sixteen months after onset of the condition, her crocodile tear phenomenon occurred spontaneously. Three acupuncture points on the face were stimulated with fine needles for 10 minutes. Her crocodile tears disappeared completely with the first acupuncture session. This case suggests the possibility of acupuncture treatment for aberrant regeneration after facial nerve palsy.

Migraña oftalmopléjica: variantes y secuelas: comunicación de cuatro observaciones / Ophthalmoplegic migraine: variants and consequences: communication of four observations

La migraña oftalmopléjica es una condición de la infancia caracterízada por crisis de severa cefalea hemicraneal seguida de parálisis ipsolateral de los nervios tercero, cuarto o sexto. Modernamente se explica mediante la teoría trigémino-vascular de la migraña. Aunque suele ser autolimitada puede dejar secuelas. Los autores comunican los casos de cuatro pacientes: tres niños con parálisis del tercer nervio craneal: una de ellas, desarrolló en el tiempo una regeneración aberrante secundaria, situación excepcional descrita en la literatura internacional en menos de diez pacientes. El último, un adulto con dos episodios de parálisis del sexto nervio craneal y una del tercer nervio. Se discuten sus manifestaciones clínicas y neurorradiológicas.

Ophthalmoplegic migraine in childhood is a painful migraine or headache complicated by an isolated III, IV or VI oculo-motor nerve palsy followed by total resolution without sequelae. The pathogenesis is unclear, however, more recently an hypothesis of trigeminovascular system activation have been proposed. The authors reported four patients with ophthalmoplegic migraine: three children with third cranial nerve palsy; one of them developed secondary aberrant regeneration of the third nerve. It is an exceptional case, because in the international literature less than ten patients had been reported. One case was an adult patient with recurrent nerve palsy (two episodes of sixth cranial nerve palsy and one event of third nerve palsy). Clinical and neuroradiological manifestations are discussed.

A Case of Congenital Oculomotor Nerve Palsy with Synergistic Divergence

PURPOSE: To report a case of unilateral oculomotor nerve palsy with synergistic divergence. METHODS: A 30-year-old man presented with outward and downward deviation of the right eye, ptosis of both eyes, and abnormal eyeball movement on left gaze since birth. His corrected visual acuity was 0.1 in the right eye and 0.7 in the left eye, indicating amblyopia in the right eye. Both eyes had high myopia of 10 diopter. In the primary position, there was a right exotropia of 70 prism diopter (PD) and hypotropia of 20 PD at both near and distance, accompanying ptosis of both eyes. Ocular motility examination revealed the absence of adduction in the right eye and the supraduction difficulties in both eyes, with a simultaneous abduction of both eyes on levoversion. The electrooculographic record of the patient showed that the movement of the right eye is always opposite to that of the left eye on levoversion. We performed lateral rectus recession 10 mm, medial rectus tucking 8 mm, and inferior rectus recession 3 mm in the right eye. Postoperatively, exotropia and hypotropia was reduced to each 10 PD and 4 PD, but there was no improvement of synergistic divergence. RESULTS: This case is thought to be a synergistic divergence combined with the oculomotor nerve palsy. The horizontal muscle surgery reduced the exotropia but did not improve the synergistic divergence in this patient.

Congenital Levator-Inferior Rectus Synkinesis

We examined a 4-year-old girl who had showed retraction of the left upper eyelid on downward gaze since birth. She had no history of birth trauma, eye surgery, or oculomotor nerve palsy. Corrected visual acuity was 0.3 OU. Motility examination revealed no phoria or tropias. Full ductions and versions were present in all fields of gaze. In primary gaze, the upper eyelids were in normal position and symmetric, and the levator function of the both eyes was normal. On downward gaze, the left upper eyelid was retracted 3.5 mmcompared with the right upper lid. On left and downward gaze, the left upper lid retraction increased to 8 mm. Result of computed tomography of brain and orbits was normal. This case is clinically rare and may be the first report of congenital levator-inferior rectus synkinesis in the Korean literature.

The Etiology and Clinical Feature of the Third, Fourth, and Sixth Cranial Nerve Palsy

40 patients who were diagnosed as the palsy of the third, fourth and sixth cranial nerve at Seoul national university hospital, were evaluated to reveal the etiology and clinical feature. The palsy of sixth cranial nerve is most common, and those of third and fourth cranial nerve followed it. Trauma was the most common cause of the palsy of the third, fourth, and sixth cranial nerve. Most of the palsy of the third cranial nerve involved both upper and lower branch, and aberrant regeneration was observed at 8 cases and its major cause was also trauma. The palsy of sixth cranial nerve was more frequently accompanied other cranial nerve palsy than those of the other two. Average recovery rate was 44.8% and, that of the sixth cranial nerve was higher than those of the other two.