Download Pontine CVA?

Ocular Motility II
Kenn Freedman M.D.
Supranuclear
Cranial Nerves
Extra-ocular Muscles
Older woman with diabetes suffered sudden
onset of Right IIIrd nerve palsy, left elevation
defect and left sided weakness
Oculomotor Nerve
• Complex Nucleus in Midbrain
• Exits interpeduncular space passing several
vessels including PCA
• Cavernous sinus
• Superior Orbital Fissure
• Superior and Inferior Divisions
• Superior: Levator and SR
• Inferior: MR, IR, IO
Left IIIrd Nerve palsy
Third Nerve Palsy
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Aneurysm
Microvascular – DM, HTN, heart disease
Trauma
Neoplasm
Syphilis
Other, Undetermined
Third Nerve Palsy
Third nerve palsy
Microvascular
Young woman presented with left sided headache and
drooping of her eyelid
Patient could not move her eye up, down or
toward her nose, but she could abduct. Her
pupil on the left was much larger than the
right.
PCA Aneurysm
Bilateral Ptosis with poor movement
except abduction
Nuclear IIIrd nerve palsy
Brainstem Syndromes
• Weber’s - ipsalateral pupil involved IIIrd
- contalateral hemiplegia
- fasicle of IIIrd Nerve where
traverses cerebral peduncle
• Benedikt’s – ipsalateral pupil involved IIIrd
- contralateral limb intention tremor,
hypokinesia and ataxia
- Fasicle of IIIrd nerve as it traverses
the red nucleus
Management of Third Nerve
Palsy
• When to do neuro-imaging and/or arteriogram?
• Important factors:
PAIN,
PUPIL,
PROGRESSION
Other Possible testing: CBC, ESR, BS
In general
You get imaging on
PUPIL INVOLVED
Third nerve palsies
Relative Pupil Sparing
0.5mm <Anisocoria < 2mm
(Larger pupil still RTL)
• Out of 24 patients:
• 10 - had compressive lesions!
• 10 - “infarction”
• 4 - other
Neurology 2001; 56: 797
Imaging Options
• MRI
• MRA – no contrast
• Cerebral Arteriogram – some risk
Management Isolated Third
Nerve Palsy
If patient is diabetic/ hypertensive and the
pupil is not involved and they do not have
too much pain*, then it would be reasonable
to follow them up without imaging studies,
depending on your comfort level. You
should see some resolution of a
microvascular palsy in at least two months.
Aberrant Regeneration
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One of many possible findings due to
misdirection of axon fibers as healing occurs
1. Lid retraction on downgaze
2. Lid elevation or pupil constriction with
attempted adduction
3. Globe retraction with attempted upgaze or
downgaze
4. Others also possible
Aberrant Regeneration
Lid Lag on Downgaze
• Congenital Ptosis
-Levator Maldevelopment
• Graves Ophthalmopathy
• Surgery, Trauma
• Aberrant Regeneration of 3rd
-pseudo von Graefe’s phenomenum
Primary Aberrant Regeneration?
• Motility problems like those described
above without an acute third nerve palsy
preceding them.
• Suggestive of a cavernous sinus mass
Trochlear Nerve
• Superior Oblique
• Long course of nerve from posterior midbrain to orbit
Midbrain
Fourth Nerve Palsy
Note head tilt
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Nerve Palsy
Diplopia –usually vertical
Sometimes Cyclo-diplopia
Head tilt and/or turn
Diplopia can worse or better on downgaze
Findings can evolve over time
Fourth Nerve Palsy
• Hypertropia
• Overaction of Ipsalateral Inferior Oblique
Muscle
• Underaction of SO not often obvious
• Excyclotorsion
• Incommitant
Fourth Cranial Nerve Palsy
Incommitance
• Hypertropia
• Hypertropia worse on contraleral gaze
• Hypertropia worse on ipsalateral head tilt
• E.g. “right – left - right”
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or
“left - right – left”
Right- Left- Right
15 RHT
2 RHT
3 RHT
7 RHT
18 RHT
Three Step Test is only valid for
Neurologic and not mechanical
muscle problems
Assumes only one paretic muscle
Think in terms of a paretic muscle
DX: Left SO palsy
Excylotorsion
• With red maddox rod over Right and white over Left
Shows a right excylcotorsion consistent with
a right SO palsy
Fourth Nerve Palsy
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Congenital*
Traumatic
Microvascular
Neoplasm
Aneurysm – not common
Other
* Congenital – often decompensate later in life
with “sudden” onset of diplopia, will have large
vertical fusional amplitudes
Fourth Nerve Palsy
(Traumatic)
Upshoot in adduction characteristic of
Overaction of left inferior oblique
Upshoot in Adduction
• Most Commonly IOOA
• DVD
• Duane’s Syndrome
Right Fourth Nerve Palsy
Bilateral Fourth Nerve Palsy
• Alternating Hypertropia
e.g. LHT in right gaze
RHT in left gaze
• Large Excyclotorsion >10-15 degrees
• V pattern
Vertical Misalignment
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Fourth Nerve Palsy
Graves Disease
Post-operative muscle problem
Skew Deviation
Third Nerve Palsy –inferior or superior division
Brown’s Syndrome
Other Orbital Disease
Plus More
Management of Isolated Fourth
Nerve Palsy
• Usually no work up necessary as most cases
are traumatic or congenital. If no history of
trauma or signs of congenital palsy then :
• Does patient have vasculopathic risk
factors?
• Yes: Observe
• No: Medical evaluation, maybe image
New onset diplopia
Abduction Deficit
Patient asked to look
To the left
Abduction Deficit
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Sixth Cranial Nerve Palsy
Graves Ophthalmopathy
Myasthenia Gravis
Orbital – tumor, inflammatory
Duane’s Syndrome Type I
Medial Wall Fracture
Past LR recession
More!
What’s this abduction deficit due to?
Patient had R+R OS for Exotropia, why does
she have decreased abduction?
Duane’s Syndrome
Agenesis of sixth nerve nucleus and , with abberent
innervation of the Lateral Rectus muscle by branches third
cranial nerve, hence multiple motility problems can be
seen
Duane’s Type I
Type II
Type III
Duane’s Syndrome
• For Example Duane’s Type I
loss of abduction, often esotropic
(no diplopia)
variable loss of adduction
narrowing of fissure on attempted abduction
upshoot or downshoot in attempted adduction
possible
Sixth Nerve Palsy
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Microvascular
Neoplastic (Posterior Fossa, Orbit, Cavernous sinus, etc)
Trauma
Increased Intracranial Pressure
Aneurysm
Post-viral and post-immunization
Other – MS, Syphilis, PML
Undetermined
Sixth Nerve Palsies in Children*:
1. Tumors 45%
2. Increased ICP (15%) non-tumor
3. Traumatic 12%
4. Congenital 11%
5. Inflammatory 7%
6. Miscellaneous 5% (post-immunization,
post-viral)
7. Idiopathic 5%
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* JPOS; 1999; 36: 305
Brainstem Syndromes
with Sixth Cranial Nerve Palsy
• Foville’s Syndrome* - lesion in region of sixth nerve nucleus
- ipsalateral gaze palsy, facial palsy, loss of
taste, Horner’s Syndrome, facial anesthesia,
deafness
• Millard-Gubler Syndrome – Sixth and
contralateral hemiparesis
Primary
Closing Lids
What’s Wrong?
Where is at least one
lesion?
Looking Left
Pontine CVA
Insert MRI scan of Eutenaurer
Total Ophthalmoplegia, loss of
vision and ptosis OD
• Cavernous sinus tumor
probable meningioma
Multiple Cranial Nerve Palsies
(3,4,6, etc)
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Superior Orbital Fissure Syndrome
Suspect Orbital Inflammatory Process –pseudotumor,
and cellulitis (think fungal)
Cavernous SinusThrombosis
Orbital or Cavernous sinus tumor
Vascular: AV fistulas or aneurysms
Invasive Periorbital Skin Cancers with perinerual spread
GCA
Diabetic
Other: HZO, Mucocele, Wernicke’s encephalopathy,
Guillain-Barre or Miller Fisher Syndromes
Cranial Nerve Palsy
History
DM, HTN, CV disease
Neurologic disease
Shunting procedures
Pain
Age
Cranial Nerve Palsy
Exam
• Standard Eye Exam, but also include:
• Exophthalmetry
• Checking other cranial nerve function
(5,7,8) – COMPANY THEY KEEP
Cranial Nerve Palsy
Major Considerations
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Microvascular
Trauma
Neoplastic
Aneurysm
Congenital
Other: GCA, Sarcoid
Consider: MS and Myasthenia
General Approach to CN Palsies
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Other Localizing signs
Pupils
Pain
Progression
• FOLLOW-UP, microvascular palsies
resolve usually in about 2 months
Matching
• Millard-Gubler
• III
• Weber’s
• IV
• Miller Fisher
• Duanes
• VI
• Benedikt’s
• Multiple CN