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Cureus Sep 2023Oculomotor nerve (CN III) palsy (ONP) has multiple etiologies, with aneurysms and ischemic injury being the two leading causes. The presentations of these conditions...
Oculomotor nerve (CN III) palsy (ONP) has multiple etiologies, with aneurysms and ischemic injury being the two leading causes. The presentations of these conditions differ, as aneurysms commonly manifest with pupillary involvement, while ischemic-related ONP often leads to a pupil-sparing presentation. We present a 63-year-old African American male with a history of sickle cell trait, ocular sickle cell disease, and untreated hypertension that develops "down and out" left eye with a mid-dilated pupil unresponsive to light. However, the patient developed severe left upper tooth pain after the onset of the eye pain, which progressed to ONP. The patient's dental and radiographic evaluation did not indicate any obvious source for his tooth pain. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the head revealed a 7-mm saccular aneurysm with a 2-mm neck arising from the left posterior communicating artery (PCOM) aneurysm, and neurovascular surgical intervention was initiated. This case highlights the potential of referred tooth pain as an early symptom in patients with PCOM aneurysm, which physicians should be vigilant about and consider as a potential indicator of the condition. Therefore, collaboration between different specialties, including ophthalmology, neurology, neurosurgery, and dental care, is necessary to formulate a comprehensive treatment plan that effectively addresses the patient's specific needs and challenges.
PubMed: 37900534
DOI: 10.7759/cureus.46027 -
BMC Genomics Oct 2023Oculomotor nerve palsy (ONP) is a neuroparalytic disorder resulting in dysfunction of innervating extraocular muscles (EOMs), of which the pathological characteristics...
BACKGROUND
Oculomotor nerve palsy (ONP) is a neuroparalytic disorder resulting in dysfunction of innervating extraocular muscles (EOMs), of which the pathological characteristics remain underexplored.
METHODS
In this study, medial rectus muscle tissue samples from four ONP patients and four constant exotropia (CXT) patients were collected for RNA sequencing. Differentially expressed circular RNAs (circRNAs) were identified and included in functional enrichment analysis, followed by interaction analysis with microRNAs and mRNAs as well as RNA binding proteins. Furthermore, RT-qPCR was used to validate the expression level of the differentially expressed circRNAs.
RESULTS
A total of 84 differentially expressed circRNAs were identified from 10,504 predicted circRNAs. Functional enrichment analysis indicated that the differentially expressed circRNAs significantly correlated with skeletal muscle contraction. In addition, interaction analyses showed that up-regulated circRNA_03628 was significantly interacted with RNA binding protein AGO2 and EIF4A3 as well as microRNA hsa-miR-188-5p and hsa-miR-4529-5p. The up-regulation of circRNA_03628 was validated by RT-qPCR, followed by further elaboration of the expression, location and clinical significance of circRNA_03628 in EOMs of ONP.
CONCLUSIONS
Our study may shed light on the role of differentially expressed circRNAs, especially circRNA_03628, in the pathological changes of EOMs in ONP.
Topics: Humans; RNA, Circular; Oculomotor Muscles; MicroRNAs; RNA, Messenger; Up-Regulation; Sequence Analysis, RNA; Eukaryotic Initiation Factor-4A; DEAD-box RNA Helicases
PubMed: 37848864
DOI: 10.1186/s12864-023-09733-3 -
Internal Medicine (Tokyo, Japan) Jun 2024A 75-year-old woman presented with nausea and vomiting. Magnetic resonance imaging (MRI) revealed that she had a pituitary mass. A biopsy revealed lymphocytic...
A 75-year-old woman presented with nausea and vomiting. Magnetic resonance imaging (MRI) revealed that she had a pituitary mass. A biopsy revealed lymphocytic hypophysitis (LYH). Symptoms were improved by hormone replacement therapy. Although she was asymptomatic, follow-up MRI revealed an increase in the size of the mass. Intravenous methylprednisolone (IVMP) reduced the size of the mass; however, right ophthalmalgia and oculomotor nerve palsy developed. MRI showed that the pituitary mass had enlarged to the right oculomotor nerve in the cavernous sinus and to the right internal carotid artery (ICA), causing stenosis of the ICA. After IVMP administration, the symptoms dramatically improved, but ICA stenosis persisted.
Topics: Humans; Female; Aged; Oculomotor Nerve Diseases; Carotid Stenosis; Methylprednisolone; Autoimmune Hypophysitis; Recurrence; Magnetic Resonance Imaging; Carotid Artery, Internal; Diagnosis, Differential
PubMed: 37813605
DOI: 10.2169/internalmedicine.2674-23 -
Surgical Neurology International 2023Isolated oculomotor nerve palsy is a relatively uncommon symptom of pituitary adenoma that usually occurs in association with pituitary apoplexy or cavernous sinus (CS)...
BACKGROUND
Isolated oculomotor nerve palsy is a relatively uncommon symptom of pituitary adenoma that usually occurs in association with pituitary apoplexy or cavernous sinus (CS) invasion.
CASE DESCRIPTION
We report two cases of relatively small pituitary adenomas with neither apoplexy nor CS invasion presenting as isolated oculomotor nerve palsy. Both patients presented with gradually worsening diplopia, without headache or visual field defects. Magnetic resonance imaging (MRI) showed a pituitary tumor with no evidence of intratumoral hemorrhage. Computed tomography revealed a lateroposterior extension of the tumor with the erosion of the posterior clinoid process. Constructive interference in steady-state MRI revealed compression of the oculomotor nerve by the tumor at the oculomotor triangle. The patients underwent endoscopic transsphenoidal surgery, and the intraoperative findings showed that the tumors did not invade the CS. The tumors were completely resected, and the oculomotor palsies resolved fully.
CONCLUSION
These cases illustrate the need to consider isolated oculomotor nerve palsy as an initial manifestation of a relatively small pituitary adenoma with neither apoplexy nor CS invasion. Based on the characteristic radiological findings, early surgical treatment is recommended to preserve oculomotor function.
PubMed: 37810282
DOI: 10.25259/SNI_421_2023 -
BMJ Neurology Open 2023Post-thrombectomy subarachnoid haemorrhage (SAH) can result in oculomotor palsy and drowsiness, which may falsely suggest transtentorial herniation.
INTRODUCTION
Post-thrombectomy subarachnoid haemorrhage (SAH) can result in oculomotor palsy and drowsiness, which may falsely suggest transtentorial herniation.
CASE PRESENTATION
We present a case of right oculomotor nerve palsy presenting after endovascular thrombectomy (EVT) for a right middle cerebral artery (MCA) stroke. The patient presented with a significant right MCA syndrome and a National Institutes of Health Stroke Scale (NIHSS) score of 10 with CT perfusion demonstrating a large penumbral lesion and a CT angiogram confirming a right MCA M1 occlusion. After thrombectomy, the patient developed a 9mm dilated non-reactive right pupil, and a new ipsilateral near-complete oculomotor nerve palsy. Repeat code stroke imaging demonstrated perimesencephalic SAH). The patient was managed expectantly and her conscious state and oculomotor palsy gradually resolved with an excellent neurological recovery.
CONCLUSION
This case underscores the potential for post-thrombectomy perimesencephalic SAH as a rare mimic of symptomatic intracranial haemorrhage with mass effect manifesting as sudden-onset oculomotor nerve palsy.
PubMed: 37808515
DOI: 10.1136/bmjno-2023-000500 -
American Journal of Ophthalmology Feb 2024It has been supposed that rectus muscle paralysis would cause proptosis due to the reduction in active posterior tension. This study aimed to test this proposition by...
PURPOSE
It has been supposed that rectus muscle paralysis would cause proptosis due to the reduction in active posterior tension. This study aimed to test this proposition by evaluating globe translation during horizontal duction in patients with abducens palsy.
DESIGN
Prospective, single-center, fellow-eye controlled, case series.
METHODS
Horizontal globe rotation and translation were quantified using orbital magnetic resonance imaging of patients with isolated unilateral abducens nerve palsy without other ocular motility disorders. Unaffected fellow eyes served as the control group. Digital image analysis was performed.
RESULTS
The study included 5 female and 2 male patients with a mean ± standard deviation age of 52 ± 15 years. The average esotropia was 39.0 ± 9.6 diopters. Mean adduction was similar at 54.9 ± 10.4° in palsied eyes and 52.0 ± 7.1° in fellow eyes. However, abduction in palsied eyes was significantly less at 11.4 ± 7.1° than 37.1 ± 11.4° in fellow eyes (P = .0023). Average anterior translation in adduction was 0.46 ± 0.42 mm in palsied orbits, similar to 0.35 ± 0.47 mm in fellow orbits (P = .90). Anterior translation in abduction averaged 0.17 ± 0.53 mm in palsied orbits, similar to 0.27 ± 0.73 mm in fellow orbits (P = .80). Average medial translation in adduction at 0.32 ± 0.23 mm in palsied orbits was statistically similar to 0.12 ± 0.44 mm in fellow orbits (P = .54). Average lateral translation in abduction at 0.19 ± 0.18 mm in palsied orbits was similar to 0.33 ± 0.15 mm in control orbits (P = .38).
CONCLUSION
Abducens palsy does not alter normal eye translation during horizontal duction.
Topics: Humans; Male; Female; Adult; Middle Aged; Aged; Prospective Studies; Abducens Nerve Diseases; Oculomotor Muscles; Esotropia; Magnetic Resonance Imaging
PubMed: 37774994
DOI: 10.1016/j.ajo.2023.09.016 -
Journal of Neuro-ophthalmology : the... Jun 2024The significance of asymmetric enhancement on cavernous sinus MRIs in the differential diagnosis of ischemic and inflammatory oculomotor cranial nerve (OCN) palsies...
BACKGROUND
The significance of asymmetric enhancement on cavernous sinus MRIs in the differential diagnosis of ischemic and inflammatory oculomotor cranial nerve (OCN) palsies remains controversial. This study explored the cavernous sinus MRI findings for cavernous sinus idiopathic inflammation (inflammation group), microvascular ischemic OCN palsy (ischemic group), and ocular myasthenia gravis (OMG group) patients.
METHODS
A total of 66, 117, and 60 patients were included in the inflammation, ischemic, and OMG groups, respectively. Cavernous sinus MRIs were retrospectively analyzed.
RESULTS
The abnormality rates of cavernous sinus MRIs for OMG and ischemic groups were 41.7% (25/60) and 61.5% (72/117), respectively. Inconsistency rates between clinical topical diagnosis and imaging findings for inflammation and ischemic groups were 3.0% (2/66) and 13.7% (16/117), respectively ( P = 0.020). In the inflammation group, cavernous sinus thickness, thickening enhancement, and enhancing adjacent lesions were noted in 90.9% (60/66), 71.2% (47/66), and 25.8% (17/66) of the patients, whereas in the ischemic group, they were noted in 51.3% (60/117), 38.5% (45/117), and 0.9% (3/117) of the patients, respectively ( P < 0.001). Among ischemic CN III palsy patients, 55.5% (15/27) and 16.7% (2/12) of the cases had CN III enlargement and enhancement in the diabetic and nondiabetic groups, respectively ( P = 0.037).
CONCLUSIONS
Cavernous sinus MRI abnormalities can be explained by specific pathologic mechanisms of the primary disease based on the complex neuroanatomy. However, suspicious inflammatory changes cannot exclude the possibility of ischemia and over reliance on these findings should be avoided.
Topics: Humans; Male; Cavernous Sinus; Female; Magnetic Resonance Imaging; Middle Aged; Oculomotor Nerve Diseases; Retrospective Studies; Adult; Aged; Young Adult; Adolescent; Oculomotor Nerve; Aged, 80 and over; Diagnosis, Differential; Ischemia; Child
PubMed: 37751328
DOI: 10.1097/WNO.0000000000001958 -
Cureus Aug 2023Third nerve palsy (TNP) is a neurologic condition characterized by dysfunction of the oculomotor nerve, leading to various ocular manifestations. Optic nerve evaluation...
Third nerve palsy (TNP) is a neurologic condition characterized by dysfunction of the oculomotor nerve, leading to various ocular manifestations. Optic nerve evaluation is of utmost important among all cranial nerve palsies affecting the eye. Dysfunction of the third nerve can indicate an underlying neurologic emergency, such as cavernous arteriovenous fistula or giant cell arteritis. Early recognition and prompt treatment are vital in reversing the clinical and visual impairments associated with oculomotor nerve palsy. The typical presentation of isolated TNP involves deviation of the eye in a downward and outward direction, accompanied by ptosis (drooping of the eyelid) and, potentially, pupil involvement. The decision to use vascular imaging is influenced by factors such as age and clinical risk for an aneurysm. If TNP is isolated or partially present with pupil involvement, it suggests compression of the third nerve and necessitates immediate imaging. Given the serious implications of an intracranial aneurysm, physicians often prioritize vascular imaging during the initial evaluation, if available. However, if clinical findings indicate underlying microvascular ischemia, a delay in imaging may be considered. This case series aims to explore the role of radiologic imaging in understanding the etiology, patterns, and clinical implications of TNP.
PubMed: 37746364
DOI: 10.7759/cureus.43986 -
Risk Management and Healthcare Policy 2023In Weber syndrome, one side of the cerebral peduncle of the midbrain is infarcted due to the occlusion of the interpeduncular branch of the posterior cerebral artery and...
BACKGROUND
In Weber syndrome, one side of the cerebral peduncle of the midbrain is infarcted due to the occlusion of the interpeduncular branch of the posterior cerebral artery and the posterior choroidal artery, resulting in ipsilateral oculomotor nerve palsy and contralateral hemiparesis. However, Weber syndrome induced by simple anterior choroidal artery lesions has rarely been reported.
CASE DESCRIPTION
Computed tomographic angiography revealed occlusion of the left internal carotid artery in a 57-year-old male patient who was admitted to the Beijing Haidian Hospital with cerebral infarction. Thrombectomy to clear the occlusion of the left internal carotid artery and the middle cerebral artery was successfully performed in the emergency department. However, postoperative digital subtraction angiography indicated occlusion of the middle and distal segments of the left anterior choroidal artery. After recovery from anesthesia, the patient had left blepharoptosis, inability to abduct the left eye, limitation of the upward and downward gaze, left mydriasis, absence of response to light, and right hemiplegia. Complete head magnetic resonance imaging suggested left cerebral peduncle and basal ganglia infarction. Therefore, the diagnosis was that the patient had left Weber syndrome caused by a left anterior choroidal arterial embolism.
CONCLUSION
When the anterior choroidal artery is the dominant supplier of blood to the medial region of the ipsilateral cerebral peduncle, the occlusion of this artery may lead to ipsilateral Weber syndrome.
PubMed: 37724309
DOI: 10.2147/RMHP.S427893 -
American Journal of Ophthalmology Case... Dec 2023This is a case of myasthenic incomplete ophthalmoplegia mimicking a partial cranial nerve 3 palsy both subjectively and objectively improving after treatment with...
PURPOSE
This is a case of myasthenic incomplete ophthalmoplegia mimicking a partial cranial nerve 3 palsy both subjectively and objectively improving after treatment with eculizumab.
OBSERVATIONS
We chronicle a case of severe generalized myasthenia gravis including myasthenia masquerading as a partial cranial nerve 3 palsy, refractory to pyridostigmine, mycophenolate, prednisone, intravenous immunoglobulin and plasma exchange but responsive to eculizumab.
CONCLUSIONS AND IMPORTANCE
This case demonstrates ocular and generalized myasthenia gravis refractory to several other therapies but amenable to eculizumab infusions, suggesting this medication may be of significant value in these difficult cases, and should be further explored for refractory ocular myasthenia gravis.
PubMed: 37711751
DOI: 10.1016/j.ajoc.2023.101925