1/52. Wegener's granulomatosis with unusual cavernous sinus and sella turcica extension. Intracerebral extension of Wegener's granulomatosis (WG) is rare. We present a patient with oculomotor and trochlear nerve palsy with histologically proved WG. An MR examination revealed granulomatous tissue in nasal cavity, paranasal sinuses with meningeal infiltration, and uncommon penetration into cavernous sinus and sella turcica. The MR images before and during pharmacological therapy are presented. ( info) |
2/52. Fresnel membrane prisms: clinical experience. BACKGROUND: There are few published reports on the clinical application of Fresnel membrane prisms in the treatment of diplopia in adults. The authors describe the use of these prisms in patients with fourth and sixth cranial nerve palsies, restrictive motility caused by thyroid-related orbital disease, and convergence insufficiency. methods: Of 209 patients who had been treated with Fresnel prisms, 141 were selected. The database included patients from a private practice in Montreal, seen from 1988 to 1996, and patients seen by orthoptists in the ophthalmology department of a children's hospital in Montreal between 1992 and 1996. All the patients had diplopia associated with fourth (48 patients) or sixth (43 patients) cranial nerve palsy, thyroid-related orbitopathy (18 patients) or convergence insufficiency (32 patients). After qualitative and quantitative assessment of the ocular misalignment, a Fresnel prism was selected for power and axis and for appropriate location on the spectacle lens. Ocular dominance and side of paresis or restriction were also considered in the placement of the prism. The patient's response to treatment was documented. RESULTS: The Fresnel prisms were oriented horizontally in 72 patients (51%), vertically in 55 (39%) and obliquely in 14 (10%). They were placed on the spectacle lens before the nondominant eye in 127 cases (90%), either covering the entire lens, or on the upper or lower segment or both. The patients were followed for an average of 15 (range 2 to 96) months. Of the 141 patients 113 (80%) had a successful outcome, with relief of their diplopia. Twenty-seven patients (19%) eventually had the prismatic correction ground into the lens, 70 (50%) chose to wear the Fresnel prism on a permanent basis because incorporation into the lens was not possible or because of cost, and 17 (12%) used the Fresnel prism as a temporary device before or after surgery. Most patients who converted to incorporated prisms did so when the prismatic power became stable, usually after 6 to 8 months. Eight patients (6%) stopped using the prism because of associated side effects, such as blurred vision, persistent diplopia, torsion or optical aberrations. INTERPRETATION: The Fresnel prism is an excellent device in treating diplopia in adult patients. It is a reasonable permanent option when incorporating the prism into the spectacle lens is not possible. A fused blurred image caused by a Fresnel prism placed in front of the nondominant eye is preferable to double but clear images. ( info) |
| A case of trochlear nerve neurinoma in a 48-year-old women is reported. She presented with pathological laughter as her principal symptom which was cured by tumour resection. A brief review of the available literature on the subject is reported. ( info) |
| A 40-year-old normotensive man suddenly developed diplopia, tinnitus and a burning sensation on the left side of his body while driving a motorcycle. He did not complain of headache, nausea or vomiting. neurologic examination revealed left trochlear nerve palsy and impaired pinprick, temperature and joint position sensation of the left limbs. There was no ptosis or motor deficit. He had a mild bleeding diathesis due to alcoholic liver cirrhosis. Computerized tomography and magnetic resonance image of the brain disclosed hemorrhages in the right midbrain tectum and the left temporal lobe. After nine months of observation, there was nearly complete recovery of symptoms, except for mild residual diplopia. From a literature review, only nine case of midbrain tectal hemorrhage involving the inferior colliculus have been reported. These patients had a unique clinical presentation. diplopia due to trochlear nerve palsy, either unilateral or bilateral, was present in all of the cases. tinnitus and sensory disturbance contralateral to the lesion side were very common. Only three patients had risk factors for hemorrhage, including bleeding diathesis, hypertension and vascular anomalies. In the majority of patients, no underlying causes were detected. The outcome was favorable with conservative treatment. ( info) |
5/52. Neuroborreliosis and isolated trochlear palsy. We report here for the first time a child with isolated trochlear palsy and neuroborreliosis. IgG and IgM antibodies against borrelia burgdorferi were highly positive in serum and cerebrospinal fluid respectively. The symptoms resolved completely after initiation of antibiotic treatment with ceftriaxone. ( info) |
6/52. Traumatic trochlear nerve palsy following minor occipital impact--four case reports. Four patients presented with transient trochlear nerve palsy following occipital impact. The impact was slight in all patients, and neuroimaging found no lesions of the nerve. Three patients had delayed onset. Two patients did not complain of diplopia, but were only aware of blurred vision. In such patients, the head tilting test was useful for diagnosis. Minor occipital impact can cause trochlear nerve palsy, which requires careful neurological examinations to identify. ( info) |
7/52. Medial transposition of the lateral rectus muscle in combined third and fourth nerve palsy. Surgical treatment of combined third and fourth nerve palsy is a challenging problem in strabismology. Five of the 6 extraocular muscles are paralyzed, which leaves the lateral rectus muscle with no antagonist to counteract its activity and usually results in a maximal exotropia. The goal of surgery is to achieve orthophoria in primary position with limited ductions. Because some believe that a conventional recession-resection procedure will inevitably result in a drift back to exotropia,(1) several other methods have been proposed to treat this disorder. These include temporal mattress suture,(2) eye muscle prosthesis, (3,4) splitting and reattaching the lateral rectus muscle near the vortex veins,(5) and fixation of the eye with fascia lata.(6) Taylor(7) suggested using medial transposition of the lateral rectus muscle in a case of isolated third nerve palsy. We report the outcome of a procedure that included such a transposition for the treatment of combined third and fourth nerve palsy. ( info) |
| sjogren's syndrome (SS) is a systemic lymphoproliferative, autoimmune disease, which is characterized by dryness of the eyes, mouth, and other mucous membranes. The nervous system may be affected in up to 20% of the cases of primary or secondary SS. We present a case of a 54-year-old woman with trochlear nerve palsy complicating sjogren's syndrome secondary to rheumatoid arthritis. We suggest that all patients with multiple cranial neuropathies, especially when associated with rheumatoid arthritis, should be carefully examined for the possible presence of secondary SS. ( info) |
9/52. Apoplexy of a pituitary macroadenoma with reversible third, fourth and sixth cranial nerve palsies following administration of hypothalamic releasing hormones: MR features. pituitary apoplexy in patients with pituitary macroadenomas can occur either spontaneously or following various interventions. We present a case of a 71-year-old woman who developed third, fourth, and sixth cranial nerve palsies following administration of the four hypothalamic releasing hormones for routine preoperative testing of pituitary function. The MR examination showed interval tumor growth with impression of the floor of the third ventricle. There were also changes in signal intensity characteristics of the mass, suggestive of intratumoral bleeding. A transsphenoidal surgery with subtotal resection of the pituitary adenoma was performed. Microscopical examination revealed large areas of necrosis and blood surrounded by adenomatous tissue. Third, fourth, and sixth cranial nerve palsies completely resolved within 4 months. We conclude that MR imaging is useful in the demonstration of pituitary apoplexy following preoperative stimulation tests, but we suggest that these tests should be abandoned in patients with pituitary macroadenomas. ( info) |
10/52. Painful fourth cranial nerve palsy caused by posteriorly-draining dural carotid-cavernous sinus fistula. A 65-year-old man with a dural carotid-cavernous fistula (DCCF) presented with sudden onset of painful trochlear nerve paresis. Typical signs of DCCF including conjunctival arterialization, chemosis, and proptosis did not become manifest until 4 months later. This unusual presentation of DCCF was caused by drainage of the fistula posteriorly into the inferior petrosal sinus with low flow. With this condition, patients may present with trochlear nerve palsy without a red eye. Although rare, DCCF must be considered in patients presenting with isolated painful trochlear palsy. ( info) |