Cases reported "Trochlear Nerve Diseases"

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11/52. Remission of superior oblique myokymia after microvascular decompression.

    Superior oblique myokymia (SOM) is an ocular motility disorder characterized by oscillopsia, vertical or torsional diplopia, sometimes combined with pressure sensation. Although the pathophysiological basis is unclear, isolated case reports have documented its association with intracranial pathological processes. We present a case of SOM associated with a vascular compression of the fourth nerve at the root exit zone. Following microneurosurgical decompression, SOM completely resolved and paralysis of the fourth nerve occurred. This was less disturbing. ( info)

12/52. Large Bielschowsky head-tilt phenomenon and inconspicuous vertical deviation in the diagnostic positions in congenital superior oblique palsy.

    PURPOSE: To report a case of congenital superior oblique palsy with an unusually large Bielschowsky head-tilt phenomenon (BHP) and disproportional inconspicuous vertical deviation. methods: Case report. RESULTS: An 18-year-old woman presented with slight compensatory head tilting and a Bielschowsky head-tilt phenomenon of 50 Delta on left tilting. magnetic resonance imaging revealed atrophy of the left superior oblique muscle. A Hess screen test showed a slight underaction of the left superior oblique muscle, but neither an obvious overaction of the ipsilateral inferior oblique muscle nor inhibitory palsy of the contralateral superior rectus muscle was found. With a 3-mm recession of the ipsilateral superior rectus muscle, Bielschowsky head-tilt phenomenon decreased to 25 Delta. CONCLUSION: A large Bielschowsky head-tilt phenomenon was possibly caused by an increased gain of the otolith-ocular reflex affecting the vertical rectus muscle. ( info)

13/52. Superior oblique palsy in a patient with a history of perineural spread from a periorbital squamous cell carcinoma.

    A 74-year-old man experienced vertical diplopia. Two years earlier, he was diagnosed with a squamous cell carcinoma of the periorbital frontal skin, with perineural spread involving the ophthalmic division of the right trigeminal nerve and the right facial nerve. The clinical findings were consistent with a right fourth cranial nerve palsy. Computerized tomography and magnetic resonance imaging demonstrated a discrete mass involving the belly of the right superior oblique muscle. An anterior orbitotomy and biopsy demonstrated a mass extending into the belly of the superior oblique muscle. histology revealed an infiltrating squamous cell carcinoma. The possibility of perineural, direct, or metastatic spread to the superior oblique muscle should be considered in a patient with a history of squamous cell carcinoma of the head and neck. The authors believe this case to be the first report of superior oblique underaction due to involvement of the muscle by squamous cell carcinoma, presumably because of perineural spread. diagnosis was made possible by neuroimaging and histopathology. There was good short-term resolution of the patient's diplopia after radiotherapy. ( info)

14/52. Superior oblique paresis with contralateral relative afferent pupillary defect.

    BACKGROUND: The purpose of this study is to report a case of superior oblique paresis and contralateral relative afferent pupillary defect (RAPD) with normal vision in a patient with brainstem astrocytoma. methods: We correlated the patient's clinical findings with anatomical substrates on magnetic resonance imaging (MRI) findings. RESULTS: The patient had right-sided superior oblique paresis. There was a left-sided RAPD, although visual acuities and visual fields were normal in both eyes. T1-weighted, gadolinium-enhanced MRI demonstrated a hyperintense area in the right dorsal midbrain. CONCLUSION: It is suggested that the lesion damaged both the pretectal afferent pupillary pathway and fascicles of the trochlear nerve, causing a unique combination of neuro-ophthalmologic findings. ( info)

15/52. Anterior and nasal transposition of the inferior oblique muscle: a preliminary case report on a new procedure.

    PURPOSE: To describe this new extraocular muscle surgery. METHOD: Case Report of a child in need of treatment of a weak superior oblique muscle which, at surgery, was in fact found to be absent. After a prior only partially successful recession of the antagonist inferior oblique (IO), the IO muscle was detached and transposed to a new insertion in the inferior nasal quadrant converting the muscle, as a result of its functional origin being the neurovascular bundle ["Ligament of Stager"-ed], from an extorter and elevator of the globe to an intorter and depressor. RESULT: Satisfactory binocular alignment was achieved. CONCLUSION: This new surgical procedure provides significant advantages, and should be added to our surgical armamentarium. ( info)

16/52. Vascular compression as a cause of superior oblique myokymia disclosed by thin-slice magnetic resonance imaging.

    PURPOSE: To describe a case of superior oblique myokymia in which thin-slice magnetic resonance imaging (MRI) appeared to show vascular compression of the trochlear nerve. methods: A 50-year-old woman presented with episodic monocular oscillopsia. Neuro-ophthalmologic examinations showed intermittent intorsional microtremor of her right eye, diagnosed as right superior oblique myokymia. Thin-slice (1.6 mm) MRI, using spoiled gradient recalled acquisition in the steady state, was employed to examine the trochlear nerve in its course through the ambient cistern. RESULTS: Imaging disclosed a branch of the posterior cerebral artery immediately adjacent to the right trochlear nerve. CONCLUSION: These magnetic resonance findings suggest that a cause of superior oblique myokymia may be vascular compression of the trunk of the trochlear nerve. ( info)

17/52. Localization of post-traumatic trochlear nerve palsy associated with hemorrhage at the subarachnoid space by magnetic resonance imaging.

    PURPOSE: To report evaluation of traumatic trochlear nerve palsy using head magnetic resonance imaging. DESIGN: Observational case reports. methods: We examined two cases involving trochlear nerve palsy after closed head injury. RESULTS: Using a fluid attenuated inversion recovery pulse sequence, MRI showed a high-intensity lesion consistent with subarachnoid hemorrhage at the trochlear nerve area in the ambient cisterns. CONCLUSION: An impact force directed toward the tentorium can be a mechanism of injury in some post-traumatic trochlear nerve palsies. Fluid attenuated inversion recovery pulse sequence is a sensitive method for detection of abnormalities in cases associated with head injury. ( info)

18/52. Isolated bilateral trochlear nerve palsy as the first clinical sign of a metastatic [correction of metastasic] bronchial carcinoma.

    PURPOSE: To report a case with isolated, nontraumatic bilateral fourth nerve palsy as the first clinical sign of a metastatic lung carcinoma. methods: Case report. A 56-year-old man presented with isolated, nontraumatic bilateral fourth nerve palsy. magnetic resonance imaging (MRI) of the brain and orbits and, subsequently, chest x-ray and a computer tomographic (CT)-scan of the thorax, the abdomen, and the pelvis were performed. RESULTS: magnetic resonance imaging confirmed the presence of a midline brain stem lesion in the region of decussation of the trochlear nerves. Computed tomographic scan of the chest revealed that the lesion was caused by a metastatic lung carcinoma. CONCLUSION: The findings of isolated bilateral fourth nerve palsy in the absence of trauma should alert the clinician to the possibility of a posterior fossa lesion in the region of the trochlear nerves. Besides urgent scanning of the dorsal midbrain, investigations should be directed to search for the primary tumor. ( info)

19/52. Combined fourth and sixth cranial nerve palsy after lumbar puncture: a rare complication. A case report.

    Palsies of cranial nerves are well-known complications after lumbar puncture. Sixth nerve palsies are the most common. They normally occur 4 to 14 days after the lumbar puncture and spontaneously recover in a few weeks or months. The occurrence of a fourth nerve palsy following lumbar puncture however is extremely rare. We report on a patient who developed a combined contralateral fourth and sixth nerve palsy after lumbar puncture (syndrome of intracranial hypotension), requiring surgical correction for secondary diplopia. ( info)

20/52. Infundibulohypophysitis in a man presenting with diabetes insipidus and cavernous sinus involvement.

    Infundibulohypophysitis is an unusual inflammatory condition that affects the infundibulum, the pituitary stalk, and the neurohypophysis and may be part of a range that includes lymphocytic hypophysitis. Lymphocytic hypophysitis occurs mainly in women and most often presents in the later stages of pregnancy. Infundibulohypophysitis usually presents with diabetes insipidus and the cause remains unclear. The case of a 46 year old man with a 12 week history of polyuria and polydipsia is reported. Cranial diabetes insipidus was diagnosed on the basis of a water deprivation test. Initial cranial and pituitary imaging studies were normal. He subsequently developed symptoms of panhypopituitism over a period of 6-9 months and then, more acutely, developed diplopia secondary to a fourth nerve palsy. Further brain imaging studies disclosed an enhancing pituitary stalk and a left cavernous sinus lesion. An initial trial of immunosuppressive treatment did not help symptoms significantly. The diagnosis of infundibulohypophysitis was made on histological evidence. The patient was treated with prednisolone and methotrexate. At 9 months he is well, without symptoms, and the radiological abnormalities have resolved. ( info)
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