Clinical features and functional recovery of traumatic isolated oculomotor nerve palsy in mild head injury with sphenoid fracture

Traumatic oculomotor nerve palsy treated with transnasal endoscopic decompression through the optic strut

Objective

To present a surgical treatment regimen of transnasal endoscopic decompression through the optic strut for traumatic oculomotor nerve palsy based on the anatomical study of the superior orbital fissure and the oculomotor nerve fissure segment.

Methods

The bone structure of the oculomotor nerve fissure segment and the important bone anatomical landmarks of the lateral wall of the sphenoidal sinus were identified on a dried skull and a cadaveric head, respectively, using a nasal endoscope, and a surgical plan was determined. Decompression was conducted on the orbital apex, the superior orbital fissure, the optic canal and the optic strut of the two patients in sequence, after which the degree and range of decompression were identified by three-dimensional (3D) computed tomography (CT).

Results

The oculomotor nerve had a close correlation with the lateral surface of the optic strut. The transnasal endoscope was employed to identify the lateral optic-carotid recess (LOCR), as well as the positions of the optic nerve, internal carotid artery (ICA), and superior orbital fissure, collectively called the "optic strut triangle". The surgical plans for decompression of the orbital apex, superior orbital fissure, optic canal, and optic strut and the necessity of optic strut drilling were determined, and the surgical procedures for safe drilling of the optic strut were elaborated. After surgery, the two patients had significantly improved symptoms, without complications. In addition, their postoperative CT showed that the medial margin of the superior orbital fissure was fully decompressed.

Conclusion

The optic strut triangle is a crucial anatomical landmark in the decompression of the oculomotor nerve, and optic strut drilling is necessary for such decompression. For patients with traumatic oculomotor nerve palsy and fractures of the medial wall of the superior orbital fissure on CT, the oculomotor nerve fissure segment can be decompressed in an effective, complete and safe manner as per the surgical plan of decompressing the orbital apex, superior orbital fissure, optic canal and optic strut in turn under a transnasal endoscope, conducive to the recovery of neurological function of patients.

Oculomotor nerve palsy presumably caused by cisternal drain during microsurgical clipping

Background:

Oculomotor nerve palsy can be caused by diverse etiologies, but no report has yet documented its association with a cisternal drain.

Case Description:

A 35-year-old woman presented with severe headache. The patient did not exhibit oculomotor nerve palsy at presentation. Cranial computed tomography (CT) revealed diffuse subarachnoid hemorrhage. The patient underwent open microsurgical clipping of a ruptured middle cerebral artery aneurysm. During surgery, a cisternal drain was placed in the basal cistern at the medial aspect of the clinoidal portion of the internal carotid artery. The patient presented with the left oculomotor nerve palsy immediately after surgery. CT revealed displacement of the cisternal drain to the lateral aspect of the anterior clinoid process. The patient’s mydriasis and sluggish light reaction recovered after 7 days, while extraocular movements persisted for 50 days. The constructive interference steady-state sequence detected the left oculomotor nerve coursing adjacent to the clinoidal internal carotid artery.

Conclusion:

Oculomotor nerve palsy can be caused by collision with a thin silastic tube placed during surgery for aneurysmal subarachnoid hemorrhage. Withdrawal of the drain as early as possible is recommended when drain-associated oculomotor nerve palsy is suspected.

High-resolution magnetic resonance imaging in isolated, traumatic oculomotor nerve palsy: A case report

Traumatic, isolated oculomotor nerve palsy is a rare clinical finding and only few reports demonstrate associated magnetic resonance imaging (MRI) findings. Here, we present the case of a 70-year-old woman with left-sided oculomotor nerve palsy following a mild head trauma due to an e-bike accident. Post-traumatic cerebral computed tomography revealed punctiform hemorrhage in the left interpeduncular cistern and the following MRI confirmed an intraneural hemorrhage of the left oculomotor nerve. Nine weeks later, the follow-up MRI showed progressive atrophy and contrast-enhancement of the left oculomotor nerve. To support functional recovery, a treatment with intravenous corticosteroids was started. Six months later, the patient presented with improved oculomotor nerve function and partial recovery of ptosis and diplopia. In accordance, MRI demonstrated recurrent contrast-enhancement of the atrophic nerve. In conclusion, high-resolution MRI allows the reliable delineation of the oculomotor nerve and can support diagnosis in trauma patients with isolated oculomotor nerve palsy.

Dual effects of thyroid hormone on neurons and neurogenesis in traumatic brain injury

Thyroid hormone (TH) plays a crucial role in neurodevelopment, but its function and specific mechanisms remain unclear after traumatic brain injury (TBI). Here we found that treatment with triiodothyronine (T3) ameliorated the progression of neurological deficits in mice subjected to TBI. The data showed that T3 reduced neural death and promoted the elimination of damaged mitochondria via mitophagy. However, T3 did not prevent TBI-induced cell death in phosphatase and tensin homolog (PTEN)-induced putative kinase 1 (Pink1) knockout mice suggesting the involvement of mitophagy. Moreover, we also found that T3 promoted neurogenesis via crosstalk between mature neurons and neural stem cells (NSCs) after TBI. In neuron cultures undergoing oxygen and glucose deprivation (OGD), conditioned neuron culture medium collected after T3 treatment enhanced the in vitro differentiation of NSCs into mature neurons, a process in which mitophagy was required. Taken together, these data suggested that T3 treatment could provide a therapeutic approach for TBI by preventing neuronal death via mitophagy and promoting neurogenesis via neuron–NSC crosstalk.

Isolate unilateral oculomotor palsy after mild traumatic brain injury

Isolated traumatic oculomotor nerve (ON) palsy is an uncommon clinical presentation of mild traumatic brain injury (TBI). There are very few cases in which it has been possible to demonstrate the isolated damage of the ON by avulsion of the roots, accompanied with traumatic axonal injury and intraneural microhemorrhage. We present a 23-year-old female who, after mild TBI, began to experience right ptosis, binocular diplopia, and photophobia. Clinical examination showed a complete ophthalmoparesis of the right ON, without other neurological deficits. Neuroimaging studies demonstrated no structural compressive damage of the right ON. Magnetic resonance imaging (MRI) with Gradient-echo and T1 weighted post-gadolinium was made, demonstrating signs of intraneural hemorrhage of the right ON, in addition to traumatic axonal injury extending from the right cerebral peduncle to the orbital fissure. Specific MRI protocols contribute as evidence of an isolated lesion to the ON.

Traumatic Ptosis: Evaluation of Etiology, Management and Prognosis

Introduction:

To investigate whether a systematic approach to subgrouping traumatic ptosis according to etiology can allow for better tailoring of prognosis and treatment.

Methods:

Retrospective chart review of patients with trauma-related blepharoptosis managed by Oculoplastic surgery specialists at an academic medical center from January 1995 to November 2015. Injury mechanism, eyelid position and function, interventions, and outcomes were reviewed.

Results:

Of 648 patients treated for blepharoptosis, 55 (8.5%) were traumatic. Careful review revealed 4 subcategories of traumatic ptosis cases: aponeurotic (n = 16), myogenic (n = 18), neurogenic (n = 7), and mechanical (n = 14). Margin reflex distance (MRD1) at presentation was significantly worse for the myogenic subtype (-0.59 mm, SD ±2.09, P = 0.046). The aponeurotic subtype had the best average levator function at presentation (14.29 mm, SD ±2.05), while myogenic had the worst (8.41 mm, SD ±4.94) (P = 0.004). Thirty-five (63.6%) patients were managed surgically. Final MRD1 was significantly different for each subtype (P = 0.163), with aponeurotic 2.63 mm (SD ±1.01), myogenic 1.29 mm (SD ±2.24), neurogenic 1.79 mm (SD ±2.48), and mechanical 2.31 mm (SD ±1.18). There was a significant increase in MRD1 from presentation to final follow up across all groups (P < 0.05).

Conclusion:

Traumatic ptosis is heterogenous. Systematically evaluating traumatic ptosis cases by trauma mechanism can guide decisions about prognosis and management. Two-thirds of cases were treated surgically, with most patients responding well to conjunctiva-Müller resection or external levator advancement. While all subgroups demonstrated improvement in MRD1 at final follow up, aponeurotic cases had the best prognosis, while myogenic fared the worst and required the longest for maximal recovery.

Functional Recovery of Cranial Nerves in Patients with Traumatic Orbital Apex Syndrome

Objective

Traumatic orbital apex syndrome (TOAS) is a rare disease characterized by the damage of cranial nerves (CNs) II, III, IV, and VI. The aim of our study was to analyze the functional recovery of CNs in TOAS and discuss the management of these patients.

Methods

We retrospectively reviewed 28 patients with TOAS treated in the Department of Neurosurgery, Shanghai Changzheng Hospital from February 2006 to February 2016. Functional recovery of CNs was evaluated based on extraocular muscle movement and visual perception. Follow-up duration was at least 6 months.

Results

There were 26 males and 2 females with a mean age of 35.3 years. The most common cause of TOAS was traffic accident. CN IV suffered the lightest injury among CNs III, IV, and VI. CN II achieved obvious improvement at 3-month follow-up, while other CNs enjoyed evident improvement at 6-month follow-up. There was no significant difference between conservative treatment and surgical decompression.

Conclusion

CNs passing through orbital apex region might recover to different degrees several months after proper management. Clinical decision should be individualized and surgical decompression could be considered with evidence of fracture, hematoma, or deformation.

Omega-3 fatty acids regulate NLRP3 inflammasome activation and prevent behavior deficits after traumatic brain injury

Omega-3 fatty acids (ω-3 FAs) attenuate inflammation and improve neurological outcome in response to traumatic brain injury (TBI), but the specific anti-inflammatory mechanisms remain to be elucidated. Here we found that NLRP3 inflammasome and subsequent pro-inflammatory cytokines were activated in human brains after TBI. Rats treated with ω-3 FAs had significantly less TBI-induced caspase-1 cleavage and IL-1β secretion than those with vehicle. G protein-coupled receptor 40 (GPR40) was observed to be involved in this anti-inflammation. GW1100, a GPR40 inhibitor, eliminated the anti-inflammatory effect of ω-3 FAs after TBI. β-Arrestin-2 (ARRB2), a downstream scaffold protein of GPR40, was activated to inhibit inflammation via directly binding with NLRP3 in the ω-3 FAs treatment group. Interestingly, we also observed that ω-3 FAs prevented NLRP3 mitochondrial localization, which was reversed by GW1100. Furthermore, ω-3 FAs markedly ameliorated neuronal death and behavioral deficits after TBI, while GW1100 significantly suppressed this effect. Collectively, these data indicate that the GPR40-mediated pathway is involved in the inhibitory effects of ω-3 FAs on TBI-induced inflammation and ARRB2 is activated to interact with NLRP3.

Electrical stimulation promotes regeneration of injured oculomotor nerves in dogs

Functional recovery after oculomotor nerve injury is very poor. Electrical stimulation has been shown to promote regeneration of injured nerves. We hypothesized that electrical stimulation would improve the functional recovery of injured oculomotor nerves. Oculomotor nerve injury models were created by crushing the right oculomotor nerves of adult dogs. Stimulating electrodes were positioned in both proximal and distal locations of the lesion, and non-continuous rectangular, biphasic current pulses (0.7 V, 5 Hz) were administered 1 hour daily for 2 consecutive weeks. Analysis of the results showed that electrophysiological and morphological recovery of the injured oculomotor nerve was enhanced, indicating that electrical stimulation improved neural regeneration. Thus, this therapy has the potential to promote the recovery of oculomotor nerve dysfunction.

Transient traumatic isolated neurogenic ptosis after a mild head trauma: a case report

BACKGROUND

Transient traumatic isolated neurogenic ptosis (TTINP) is a sporadically reported rare entity. However, to the best of our knowledge, nearly all the reported cases are either secondary to direct periorbital trauma or surgery. We would like to report on a case of TTINP with countre-coup injury of the periorbital region.

CASE PRESENTATION

A 49-year-old female slipped and fell down while walking. She was hospitalized with a moderate headache and undisturbed mental state. The patient recalled that the force bearing point was her occipital region. Physical examination and computed tomography (CT) on admission showed right isolated ptosis and mild contusion and laceration in the bilateral frontal cortex. Further radiological investigation revealed nothing remarkable except for a fracture of the superior portion of the right medial orbital wall. She was managed conservatively and recovered completely in two months.

CONCLUSION

TTINP might manifest as a unique entity with a relatively mild, reversible, and non-devastating injury to the terminal branch of the oculomotor nerve and for which perhaps no special treatment is needed. The proposed mechanism is injury of the terminal branch of the superior division of the oculomotor nerve.

The neuro-ophthalmology of head trauma

SUMMARY

Traumatic brain injury (TBI) is a major cause of morbidity and mortality. Concussion, a form of mild TBI, might be associated with long-term neurological symptoms. The effects of TBI and concussion are not restricted to cognition and balance. TBI can also affect multiple aspects of vision; mild TBI frequently leads to disruptions in visual functioning, while moderate or severe TBI often causes structural lesions. In patients with mild TBI, there might be abnormalities in saccades, pursuit, convergence, accommodation, and vestibulo-ocular reflex. Moderate and severe TBI might additionally lead to ocular motor palsies, optic neuropathies, and orbital pathologies. Vision-based testing is vital in the management of all forms of TBI and provides a sensitive approach for sideline or post-injury concussion screening. One sideline test, the King-Devick test, uses rapid number naming and has been tested in multiple athlete cohorts.

Persistent diplopia after fractures involving the orbit related to nerve injury

BACKGROUND

Fractures in the facial skeleton are common and may lead to orbital sequelae caused by the injury and/or the surgery. In this long-term follow-up, we examined the nature of sequelae after facial fractures involving the orbit and whether a higher complexity of the fractures produced more sequelae compared to simpler fracture patterns, and if so, to what extent.

METHODS

Patients surgically treated for facial fractures involving the orbit at the Karolinska University Hospital with a follow-up duration of ≥3 years were included in this retrospective study and were examined by a neuro-ophthalmologist. Based on the location and severity of the fractures, the patients were divided into four groups according to fracture complexity: 1) isolated zygomatic fracture, 2) isolated orbital floor blowout fracture, 3) zygomatic fracture combined with blowout fracture and 4) bilateral or multiple fracture patterns.

RESULTS

Out of 154 patients, 81 patients (53%) attended follow-up examinations, 65 male (80%) and 16 female (20%). The duration of follow-up was 3.0-7.6 years (mean of 4.9 years). The incidence of diplopia was 3.7%, visual loss 2.5%, dystopia 4.9% and visible enophthalmos (>2 mm) 8.6%. Severe diplopia (2.5%) was due to nerve injuries. Visual loss was encountered only in group 4 with complex fractures. Fracture complexity had an effect on the presence of any sequelae, with group 4 presenting a higher percentage of patients with sequelae than the other three groups. However, no statistically significant effect of group could be found on the individual, quantitative output values of dystopia and enophthalmos.

CONCLUSIONS

In this study, severe persistent diplopia in patients was due to nerve injuries, which emphasizes the need for preoperative ophthalmologic examinations, in all patients with fractures involving the orbit. A higher fracture complexity was found to lead to a higher percentage of patients presenting sequelae.

Infrared pupillometry, the Neurological Pupil index and unilateral pupillary dilation after traumatic brain injury: implications for treatment paradigms

Pupillary dysfunction, a concerning finding in the neurologic examination of the patient with an acute traumatic brain injury often dictates the subsequent treatment paradigm. Patients were monitored closely with an infrared pupillometer, with NPi technology, for acute changes in pupillary function. NPi technology applies a scalar value to pupillary function. A retrospective chart review was performed of traumatic brain injury patients with acute unilateral pupillary dilation, admitted to Legacy Emanuel Medical Center’s NeuroTrauma Unit, Portland, OR, and followed as outpatients, between January 2012 and December 2013. Clinical exam findings of pupillary size, NPi scores, and brain Magnetic Resonance Imaging and Computed Tomography images were analyzed. Five traumatic brain injury patients were identified with unilateral pupillary dysfunction with long-term follow-up after the initial injury. Each patient was monitored closely in the trauma bay for neurological deterioration with a pupillometer and the clinical exam. Two patients underwent subsequent intracranial pressure monitoring based on a deteriorating clinical scenario, including consistent abnormal unilateral NPi scores. One patient with consistent abnormal NPi scores and an improved clinical exam did not undergo invasive interventions. Two patients showed early improvement in NPi scores correlating with the normalization of their pupillary reactivity. Anisocoria improved in all patients despite concurrent abnormal NPi scores. Magnetic Resonance Imaging and Computed Tomography imaging studies, with a focus on the third nerve, revealed focal abnormalities consistent with the clinical findings. A unilateral blown pupil and abnormal NPi score in a traumatic brain injury patient are not necessarily indicative of intracranial pressure issues, and must be correlated with the entire clinical scenario, to determine the etiology of the third nerve injury and direct potential therapeutic interventions. Early NPi score normalization suggests pupillary function may improve. We found that NPi scores, as a component of the clinical exam, provide a sensitive, noninvasive and quantitative means of following pupillary function acutely and chronically after a traumatic brain injury.

Understanding the Neuro-ophthalmology of Head Trauma: A Review of the Current Literature

Head trauma is a major medical, social, economic, national, and public health priority issue in the United States. In severe head trauma, the overwhelming clinical manifestations are so compelling that damage to the visual system is most likely to be ignored. Both the afferent and efferent visual systems are susceptible to injury after head trauma, and physicians should be aware of the visual system and perform a thorough neuro-ophthalmic evaluation in patients presenting with head trauma.Most of the data available on neuro-ophthalmic complications of head trauma including cortical blindness, Horner's syndrome, traumatic internuclear ophthalmoplegia, and ocular motor palsy, comes from case reports highlighting the need for future studies to better understand these complications.This review summarizes some of the most important neuro-ophthalmic complications of head trauma including cortical blindness, Horner's syndrome, traumatic internuclear ophthalmoplegia, and ocular motor palsy. Search of the peer-reviewed literature was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Global Health, and MD Consult.

Isolated traumatic neurogenic ptosis with delayed recovery

PURPOSE

To describe the entity of isolated neurogenic ptosis due to presumed tractional injury to the nerve of innervation of the levator palpebrae superioris, with recovery occurring over a period up to 6 months.

METHODS

Retrospective case review.

RESULTS

Three cases of presumed neurapraxic injury to the nerve of innervation to the levator palpebrae superioris are described. Two cases had a clear history of traction to the upper eyelid. There was no evidence of damage to other extraocular muscles or their nerves of innervation in 2 cases and mild transient superior rectus underaction in 1. Maximal recovery occurred over a period of up to 6 months.

CONCLUSIONS

Traumatic neurapraxic injury to the nerve of innervation to the levator palpebrae superioris may occur in certain types of upper eyelid injury, most notably when there is significant forward traction applied to the upper eyelid. Although recovery may occur within weeks, as previously described, this series illustrates that recovery may take up to 6 months.