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.

Parálisis criptogénica del III par craneal / Cryptogenic palsy of the third cranial nerve

La parálisis aislada del tercer par craneal no es frecuente en los niños. Entre las causas que la originan se encuentran las congénitas, traumáticas, infecciosas, tumorales, vasculares, tóxicas y desmielinizantes. Se presenta un paciente de 3 años de edad con el diagnóstico de una oftalmoplejía aguda dolorosa del tercer par craneal, cuya etiología no se pudo demostrar. El cuadro clínico desapareció de forma espontánea y no ha presentado recurrencias después de 3 años de seguimiento. Se concluye que ante un paciente con parálisis del tercer par craneal es necesario realizar una exhaustiva evaluación con el propósito de precisar las diversas causas que la provocan

Isolated third cranial nerve palsy is not frequent in children. Among the causes are congenital, traumatic, infectious, tumoral, vascular, toxic and demyelinizing. This is the case of a 3-years old patient diagnosed with acute painful ophthalmoplegia of the third cranial nerve, in which etiology could not be proved. The clinical picture disappeared spontaneously and no recurrence has emerged after 3 years of follow-up. It was concluded that when dealing with a patient with third cranial nerve palsy, it is necessary to make a thorough assessment to precise over the different causes

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...

Arachnoid Cyst in Oculomotor Cistern

Oculomotor cistern is normal anatomic structure that is like an arachnoid-lined cerebrospinal fluid-filled sleeve, containing oculomotor nerve. We report a case of arachnoid cyst in oculomotor cistern, manifesting as oculomotor nerve palsy. The oblique sagittal MRI, parallel to the oculomotor nerve, showed well-defined and enlarged subarachnoid spaces along the course of oculomotor nerve. Simple fenestration was done with immediate regression of symptom. When a disease develops in oculomotor cistern, precise evaluation with proper MRI sequence should be performed to rule out tumorous condition and prevent injury of the oculomotor nerve.

Differential Diagnosis of Lemierre's Syndrome in a Patient with Acute Paresis of the Abducens and Oculomotor Nerves

Lemierre's syndrome is characterized by anaerobic septicemia, internal jugular vein thrombosis, and septic emboli associated with infections of the head and neck. We describe an unusual and clinically confusing case of a young woman with an acute paresis of the abducens nerve and partial paresis of the right oculomotor nerve. After an extensive imaging diagnostic procedure, we also documented a peritonsillar abscess and various types of thromboses in intracranial and extracranial veins. Furthermore, we found brain and lung abscesses, which led us to establish the diagnosis of Lemierre's syndrome. Despite intensive anti-coagulation and antibiotic therapy, the patient developed a mycotic aneurysm in the right internal carotid artery directly adjacent to the previously thrombosed cavernous sinus. In summary, we were able to confirm that Lemierre's syndrome may occur in conjunction with uncharacteristic symptoms. Due to the sometimes confusing clinical symptoms as well as clinical and radiological specialties, we had to work on an interdisciplinary basis to minimize the delay prior to establishing the diagnosis and therapy.

Gossypiboma: el sempiterno problema de los cuerpos extraños retenidos y el privilegio del internista / Gossypiboma: the always present problem of surgical strange object`s retention and the internis` privilege

La retención de objetos quirúrigicos o cuerpos extraños durante un acirugía, es un problema ampliamente reconocido en el sistema de atención de la salud. Causa daño a los pacientes, proveedores, hospitales, comunidades y al sistema de atención dela salud como todo. También resulta en gastos inncesarios. La retención de objetos quirúrgicos es un problema totalmente evitable. Se presenta el caso de una mujer diabética que presentó una parálisis incompleta tercer nervio central y durante la explotación física integral, privilegio del internista, se encontró un tumor abdominal asintomátco. La tomografía computarizada fue compatible con una retención de objetos quirurgicos. Este artículo exmina los factores de riesgo para que ocurra la retención, examina los métodos actuales de prevención y los estudios de las nuevas tecnologías que se han desarrollado para evitar este error médico

The retention of surgical objects is a widely recognized problem within the health care system. It causes harm to patients, providers, hospitals, communities, and to the health care system as a whole. It also results in needless expense. The retention of surgical objects is a problem completely preventable. We presented the case of a diabetic woman who presented with incomplete third nerve palsy and incidentally, as an internist`s privilege, an asymptomatic abdominal tumor was clinicaly found. The computarized tomography scan was compatible with a retention of surgical objects. This article reviews the risk factors for retention of surgical objects, examines the current methods of prevention, and surveys the new technologies that have been developed to prevent this medical error

Acute unilateral third nerve palsy as an early manifestation of central nervous system relapse in a patient with acute myeloid leukemia

The reported incidence of central nervous system [CNS] involvement by acute myeloid leukemia [AML] ranges widely from less than 10-30%. Acute unilateral third nerve palsy is an unusual first manifestation of such an event. We describe a rare ophthalmologic manifestation of CNS relapse in a 25-year-old patient with AML who had undergone allogeneic stem cell transplant, and demonstrate the value of MRI in the early diagnosis

A Case of Oculomotor Nerve Palsy and Choroidal Tuberculous Granuloma Associated with Tuberculous Meningoencephalitis

We report a rare case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis. A 15-year-old male visited our hospital for an acute drop of the left eyelid and diplopia. He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis. A neurological examination revealed a conscious clear patient with isolated left oculomotor nerve palsy, which manifested as ptosis, and a fundus examination revealed choroidal tuberculoma. Other anti-tuberculous drugs (pyrazinamide, ethambutol) and a steroid (dexamethasone) were added. After 3 months on this medication, ptosis of the left upper eyelid improved and the choroidal tuberculoma decreasedin size, but a right homonymous visual field defect remained. When a patient with tuberculous meningitis presents with abrupt onset oculomotor nerve palsy, rapid re-diagnosis should be undertaken and proper treatment initiated, because the prognosis is critically dependent on the timing of adequate treatment.

Fascicular multiple ocular motor nerve paresis as first presentation of anaplastic astrocytoma.

A case of spontaneous, painless partial III (pupil-sparing) and IV fascicular nerve paresis as the first presentation of anaplastic astrocytoma is reported. The other ocular, neurological and systemic examination was within normal limits. The literature and possible anatomical location of this atypical presentation is reviewed.

Isolated pathetick nerve paresis by compression from a dolichoectatic basilar artery: case report

The article describes a woman with 53 year-old that has presented diplopia when looking down and adopted a tilted head position in order to read for the last six months. The neuro-ophthalmic examination shows isolated right superior oblique muscle paresis. The magnetic resonance and the angioresonance show the dolicoectatic basilar artery compressing the right ventral lateral brainstem.

O artigo descreve uma mulher de 53 anos que há seis meses apresenta diplopia ao olhar para baixo, além de adotar postura inclinada da cabeça para ler. O exame neuro-oftalmológico revelou paresia isolada do músculo oblíquo superior direito. Os exames de ressonância magnética e angioressonância evidenciaram dolicoectasia da artéria basilar, que comprimia a face ventral lateral direita do tronco cerebral.

Ocular motor nerve palsy: a clinical and etiological study.

PURPOSE: To clinically describe cases of ocular motor nerve palsy and to determine the possible causes. MATERIALS AND METHODS: Thirty-one consecutive patients with ocular motor nerve palsies were investigated. All underwent complete ophthalmological, as well as neurological, otorhinolaryngological and general examination. Computerised tomography (CT)-scan of the brain and complementary laboratory tests were obtained from each participant. RESULTS: Paralysis of the sixth (38.4%) and the third (35.3%) cranial nerve were the most common. The Lees screen test was found to be very sensitive, confirming the diagnosis of ocular motor nerve palsy, even in cases with minimal manifestations. Complete ptosis and full mydriasis were mostly seen in isolated cases of the third cranial nerve palsy. The majority of eyes (63.2%) with third cranial nerve palsy had pupil sparing. Overall, an etiological diagnosis was made in 93.5% of cases. The common causes were vascular conditions (25.8%), otorhinolaryngologic diseases (19.7%) and trauma (12.9%). CT scan failed to reveal any abnormality in 54.8% of cases. CONCLUSION: Patients with ocular motor nerve palsy should be carefully examined in close collaboration with other specialists, especially where sophisticated, complementary investigations are impossible.

Metastasis to the unilateral oculomotor nucleus complex: case report

O presente relato descreve um homem de 76 anos que, após cirurgia de câncer de pulmão apresentou paralisia oculomotora extrínseca à esquerda e paralisia contralateral do músculo reto superior, além de ptose palpebral bilateral. O exame de ressonância magnética evidenciou uma rara situação caracterizada por metástase isolada na região do núcleo do terceiro nervo craniano esquerdo provavelmente comprometendo o sub-núcleo do reto superior e o núcleo central caudal, justificando assim o envolvimento óculo motor bilateral.

A Case of Multiple Cranial Nerve Palsies as the Initial Ophthalmic Presentation of Antiphospholipid Syndrome

PURPOSE: To report a case of third, fourth, and six cranial nerve palsies with antiphospholipid syndrome (APS). METHODS: Medical records of a 16 year old female diagnosed with idiopathic intracranial hypertension (IIH) in primary APS were reviewed. RESULTS: A 16 year old female presented with headache and diplopia. Ocular examinations revealed marked bilateral disc edema. She was unable to depress, adduct, and abduct in left eye and had limited abduction in the right eye. Cerebrospinal fluid had a normal composition and a pressure of 400 mmH2O. Lupus anticoagulant and IgG anticardiolipin antibody were positive. There was no clinical evidence of other autoimmune disease. Brain magnetic resonance (MR) imaging, MR angiography, and conventional angiogram with venous phase were normal. She was diagnosed with bilateral sixth, and left third and fourth cranial nerve palsies secondary to idiopathic intracranial hypertension in primary APS. CONCLUSIONS: To our knowledge this is the first reported case of concurrent third, fourth, and sixth cranial nerve palsies in a patient with primary APS.

Pseudotumor cerebri with transient oculomotor palsy.

Pseudotumor cerebri is a clinical syndrome characterized by raised intracranial pressure with normal ventricular size, anatomy and position. Headache, vomiting and diplopia are the most common symptoms. Signs include those of raised intracranial pressure including papilledema and absence of focal neurological signs. A secondary cause is identifiable in 50% of children; the most common predisposing conditions are otitis media, viral infection and medications. Management is mainly directed towards identifying and treating the cause and measures to reduce the raised intracranial pressure. Though it is mostly a self limited condition, optic atrophy and blindness can occur. Oculomotor nerve palsy is very rarely associated with pseudotumor cerebri. We report a unique case of pseudotumor cerebri who had left Oculomotor palsy with sparing of the pupillary fibres, which resolved following treatment with oral acetazolamide.

Sphenoid sinus mucocele presenting with isolated oculomotor nerve palsy.

Isolated sphenoid sinus mucoceles are rare. Patients who have these lesions can present with several different symptoms and signs such as headache, nasal symptoms, and cranial nerves 2, 3, 4, and 6 palsies. Isolated oculomotor nerve palsy is not a common presenting symptom of sphenoid sinus mucocele. However, exclusion of sphenoid sinus mucocele should be made when the patient presents with isolated oculomotor nerve palsy. A case of sphenoid sinus mucocele with isolated oculomotor nerve palsy is presented with review of the literature. The oculomotor nerve function in this patient completely recovered after endoscopic sphenoidectomy.