Diplopia Related to a Pediatric Cervical Rhabdoid Tumor in 18 F-FDG PET.

ABSTRACT: Increased muscle uptake is commonly seen with 18 F-FDG PET/CT because of an important physiological muscle glucose metabolism. Muscle uptake can express a recent significant muscle activity. However, the absence of muscle uptake is almost never described or interpreted. We describe the case of an 8-year-old boy with extrarenal rhabdoid tumor in the right carotid space. An MRI and an 18 F-FDG PET/CT were performed for the diagnostic workup. There was no uptake in the lateral rectus oculomotor muscle unlike all other oculomotor muscles. The ophthalmological examination found a diplopia confirmed by the Lancaster test.

CT parameters in pure orbital wall fractures and their relevance in the choice of treatment and patient outcome: a systematic review.

Computed tomography (CT) is commonly used for the diagnosis, treatment planning, and prognosis of pure orbital fractures of the orbital floor and medial wall. The aim of this study was to systematically review the current literature in order to establish an overview of CT parameters relevant to the choice of treatment and (long-term) clinical outcome for patients treated operatively and conservatively. The PRISMA guidelines were followed. Databases were searched using the terms 'orbital fracture' and 'computed tomography'. Studies evaluating the relationship between CT parameters and the treatment decision or clinical outcome (enophthalmos, diplopia, and/or limitation of ocular movement) were included. The search yielded 4448 results of which 31 were included (except for three, all were retrospective). The systematic use of CT imaging in orbital fractures of the floor and the medial wall can be of great value in the treatment decision and prediction of (long-term) clinical outcomes for both conservatively and surgically treated patients. The following parameters were found to be the most relevant: fracture size, fracture location, orbital volume, soft tissue involvement, and craniocaudal dimension. Although some show great individual potential, it is likely that incorporating all parameters into an algorithm will provide the best predictive power and thus would be the most practically applicable tool.

Cause of acquired onset of diplopia due to isolated third, fourth, and sixth cranial nerve palsies in patients aged 20 to 50 years in Korea: A high resolution magnetic resonance imaging study.

AIMS: This study aimed to describe the etiologies of acquired onset of diplopia due to isolated third, fourth, and sixth cranial nerve palsies in young adults in Korea. METHODS: This retrospective study included 127 patients aged 20 to 50 years with acquired onset isolated third, fourth, and sixth cranial nerve palsies who received care at the Strabismus and Neuro-ophthalmology Department of Samsung Medical Center from 2013 to 2017. The etiologies of the palsies determined by clinical assessment, high-resolution magnetic resonance imaging (MRI) with three-dimensional constructive interference in steady state, and laboratory testing were analyzed. RESULTS: Fifty-nine patients manifested sixth cranial nerve palsy. Forty-six patients had fourth cranial nerve palsy and 22 patients had third cranial nerve palsy. The most common etiologies of the ocular motor nerve palsies were presumed inflammatory lesions (21.3%), followed by presumed microvascular causes (17.3%), and neoplasms involving the central nervous system (15.7%). Neoplasms were the most common cause of sixth cranial nerve palsy (25.4%). The most common cause of fourth cranial nerve palsy was presumed microvascular ischemia (28.3%), and presumed inflammatory lesions was the most common cause of third cranial nerve palsy (36.4%). Other non-traumatic causes included vascular lesions, ischemic brainstem stroke, intracranial hemorrhage, non-aneurysmal neuro-vascular contact, multiple sclerosis, and infection. CONCLUSION: A substantial proportion of young adult patients with ocular motor nerve palsies manifested pathologies other than presumed microvascular ischemia or idiopathic causes. Neuroimaging and laboratory tests have important roles in the evaluation of patients aged 20-50 years with acquired ocular motor nerve palsies.

Intracranial arachnoid cyst rupture after mild TBI in children: have we underestimated this risk?

The association between intracranial arachnoid cyst rupture and mild brain trauma is infrequently reported. The purpose of this case report is to describe the case of a child with a left temporal arachnoid cyst who suffered rupture with haemorrhage after mild trauma during a football match. The child presented with chronic headache of mild intensity that progressed to a more intense headache after a traumatic event. He underwent surgical intervention after diagnosis of chronic haemorrhage in an arachnoid cyst in the ipsilateral subdural space. The risk of intracranial arachnoid cyst rupture should be considered during the evaluation of oligosymptomatic patients because it is a potentially catastrophic event.

Endoscopic treatment of a periorbital fat herniation caused by spontaneous solution of continuity of the papyracea lamina.

We present a case of a 16-year-old girl with interruption of papyracea lamina and herniation of the periorbital fat covered by a bone shell. The patient presents with a history of diplopia and visual disturbances ever since she can remember. Thanks to radiological imaging and biopsy, we have done differential diagnosis with periorbital lipoma, intraosseous lipoma and intramuscular lipoma of medial rectus. Diagnostic for images is necessary for a correct operative planning. Endoscopic sinus surgery with computer-assisted navigation is the safest and most effective method to remove the lesion that was closely related to the medial rectum muscle and to the anterior ethmoidal artery. The patient after surgery and in 1 year of follow-up reports the disappearance of symptoms.

Diplopia: a unique presentation of recurrence of a salivary gland carcinoma.

A 79-year-old man with a history of radical excision of a left submandibular gland carcinoma ex-pleomorphic adenoma presented with a new 2 cm lump in his left submandibular region which proved to be recurrence on surgical excision. During work up for revision surgery he developed a right VI cranial nerve palsy, which was attributed to his microvascular status having had a history of three previous transient ischemic attacks (TIAs). 6 months later, his palsy had not resolved. MRI revealed new soft tissue by the cavernous segment of the internal carotid artery. The exact source of this was unclear as there was no evidence of local recurrence or nodal disease. A repeat MRI scan 16 months later revealed further growth of abnormal tissue in the cavernous sinus and the primary submandibular location, now involving multiple nerves including branches of cranial nerves IV, V, VI, VII and XII making surgical excision impossible.

Metastasis of advanced gastric cancer to the extraocular muscle: a case report.

BACKGROUND: Metastatic tumors in the orbit, especially from gastric cancer, are rare. We present a rare case of extraocular muscle metastasis from gastric cancer and raise consideration of metastasis to extraocular muscle as a differential diagnosis of proptosis/lid swelling in a patient with history of malignancy. CASE PRESENTATION: A 54-year-old Japanese woman presented with proptosis, lid swelling, diplopia, and retro-orbital pain in her left eye, which she had been experiencing for 1 day. She had a medical history of poorly differentiated adenocarcinoma of the stomach, which had metastasized to several organs. A computed tomography scan showed enlargement of the medial rectus muscle in her left eye. She was diagnosed as having gastric cancer metastasis to the medial rectus muscle of her left eye, and received a total of 20 Gy radiation therapy to the orbit, which resulted in resolution of her ocular symptoms. She died 3 months after her initial visit to our ophthalmic department. CONCLUSIONS: Metastasis from malignancy should be considered in the differential diagnosis of a patient presenting with proptosis or lid swelling who has a history of gastric cancer. Radiation therapy of metastases in the orbit may be an effective treatment in such cases.

Correlation of Clinical Findings With Computed Tomography in Orbital Traumas.

BACKGROUND: Although the eye is a well-protected organ, it is frequently affected by trauma. The timely detection of ocular injuries is extremely important. In this study, the authors evaluated the consistency between findings in computed tomography (CT) examination for orbital fractures and globe integrity and clinical findings in patients presenting to the emergency department due to orbital trauma. METHODS: The authors retrospectively reviewed the files of patients presenting with orbital trauma between January 2015 and January 2018 from emergency department records. Ophthalmology consultation and follow-up notes, radiology reports, and the emergency physician's notes were reviewed. RESULTS: During the study period, 286 patients presented to the emergency department with orbital trauma. A total of 119 eyes of 83 patients who underwent orbital CT were included in the study. Orbital bone fracture was detected in 54.6% (n = 65) of the eyes. Of these, 73.8% (n = 48) involved multiple fractures. Among all eyes, the distribution of fractures in the orbital walls was lateral wall in 41.2% (n = 49), floor in 32.8% (n = 39), medial wall in 31.1% (n = 37), and roof in 10.9% (n = 13). Multiple wall fractures were detected in 36.9% (n = 44) of the eyes. At least 1 clinical finding such as diplopia, laceration, abnormal pupillary response, hypoesthesia, and exophthalmos was observed in 47.1% (n = 56) of the eyes. This rate was 56.8% among eyes with orbital fractures and 35.2% in those without fracture. There was a statistically significant relationship between floor fractures and diplopia (P = 0.002). No significant correlations were found between the other radiological and clinical findings. CONCLUSION: Our study revealed a relationship between the presence of orbital fracture and eye damage. In particular, the authors found that the frequency of diplopia was significantly higher in eyes with maxillary bone fracture in the orbital floor. However, orbital CT findings other than bone fracture were not consistent with clinical findings.

Relationship of clinical presentation and angiographic findings in patients with indirect cavernous carotid fistulae.

INTRODUCTION: Indirect cavernous carotid fistulae (ICCFs) can present with insidious, non-specific symptoms and prove difficult to diagnose. This study evaluates associations among ICCF symptoms and angiographic findings. METHODS: A retrospective analysis was performed of prospectively maintained records at four medical centers to identify patients with ICCFs evaluated with angiography. Patient demographics, symptoms, and angiographic findings were tabulated. Univariate and multivariate analyses were conducted to identify associations among these variables. RESULTS: Records sufficient for review existed for 267 patients evaluated with angiography. Patients were most commonly women, in the sixth or seventh decade of life, and had symptoms for months before a definitive diagnosis. The most common symptoms included proptosis, diplopia, cranial nerve palsy, and chemosis. Cortical venous reflux was most common in patients with chemosis, orbital pain, or bruit. Intracranial hemorrhage was associated with cortical reflux and bilateral inferior petrosal sinus occlusion. Patients with loss of symptoms demonstrated higher rates of inferior petrosal sinus occlusion and a trend towards rupture. CONCLUSION: A high index of suspicion is needed to promptly diagnose patients with ICCFs. High risk features are more common in the setting of chemosis, orbital pain, bruit, or spontaneous loss of symptoms. Patients with such symptoms warrant expedited angiographic evaluation.

Surgical repair of traumatic isolated inferior rectus muscle avulsion.

PURPOSE:: To report our experience in the management of avulsion of the inferior rectus muscle. METHODS:: We describe the approach we have used for surgical repair of isolated avulsion of the inferior rectus muscle in two patients who suffered orbital trauma. RESULTS:: In both cases, the proximal portion of the inferior rectus muscle was located successfully by the generated muscle force duction test and sutured back into its original insertion point. Infraduction was normal and orthotropia was present in all directions of gaze during 1 year of postoperative follow-up in both cases. These favorable outcomes are attributed in part to the inferior rectus muscle pulleys system and the natural history of this type of injury, which allows the lost proximal portion to be identified by generated muscle force duction test. CONCLUSION:: Generated muscle force duction test can be used to locate the proximal portion of a lost inferior rectus muscle and restore its function in patients with traumatic avulsion injury involving an extraocular muscle.

Does vertical incomitance predict the diplopia outcome in orbital fracture patients? A prospective study of 188 patients.

OBJECTIVE: To determine the predictive value of vertical incomitance for diplopia outcome in orbital fracture patients. PATIENTS AND METHODS: A prospective cohort study composed of patients with orbital fractures was designed. The predictor variable was vertical incomitance, and the primary outcome variable was diplopia. Incomitance was calculated in prism diopters (Δ) as the difference of the maximum absolute deviation between the upper and lower three gaze directions. Standard statistics for patient characteristics, the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables were computed. RESULTS: The sample was composed of 188 patients grouped as follows: non-operated (n = 124) and operated (n = 64). Fifty-one patients showed vertical incomitance of whom 10 (19.6%) had persistent diplopia at the 1-year follow-up. The mean incomitance was 9.6Δ in the diplopia group versus 2Δ in the non diplopia group (OR = 1.13; p < 0.001). There was a statistically significant association between vertical incomitance of >2Δ and persistent diplopia at 1 year after adjusting for the surgery variable (OR = 1.07; p < 0.04). CONCLUSION: The present study has demonstrated that in orbital fracture patients, vertical incomitance was associated with (1) persistence of long-term diplopia, (2) the decision to perform surgery, and (3) the severity of the fracture.

[Diplopia/Double Vision].

Here, I review the efficacy of radiological methods in the diagnosis of diplopia/double vision. The simplest technique for achieving a successful diagnosis is to capture a wide field-of-view image. In order to start the process of diagnosis, it is fundamental to first study the image findings. Analysis based on the principle of MECE or mutually exclusive collectively exhaustive is performed using four methods: deductive reasoning, fractionation, longitudinal study, and priority setting. The conventional practical procedure to attain a diagnosis is as follows. First, identify the location of the lesion by imaging, which will shorten the list of differential diagnosis. Second, obtain as much information as possible on the characteristics of the lesion in order to determine the pathology. Third, look for any associated findings, such as tortuous vasculature around the brain. Fourth, refer to all the available information; for example, the main complaint, clinical history, previous history, family history, physical findings, physiological findings, laboratory data, previous images, and other modalities. Finally, if still in doubt, one should consult with colleagues and the attending physician. However, because rationality (statistical analyses, such as posterior probability or positive predictive value with positive findings), predicted utility, and emotions play a factor in a person's decision making, it seems impossible to completely avoid oversights and misdiagnosis.

Presenting Symptoms of Pituitary Apoplexy.

The classical term "pituitary apoplexy" (PA) describes a clinical syndrome usually characterized by abrupt onset of headache accompanied by neurologic and/or endocrinologic deterioration due to sudden expansion of a mass within the sella turcica as a result of hemorrhage or infarction within a pituitary tumor and adjacent pituitary gland. PA is a medical emergency and a difficult diagnosis to establish. Thus this article reviews the presenting symptoms of PA patients to help clinicians recognize or at least suspect this critical condition early on. PA commonly occurs in the setting of a preexisting adenoma, and several patients are unaware of its existence prior to the onset of apoplexy symptoms, which are mainly of a neurologic, ophthalmologic, and endocrinologic nature. Neurologic symptoms include sudden-onset severe headache and other symptoms of subarachnoid hemorrhage, symptoms from compression of the cavernous sinus contents, nausea/vomiting, impaired consciousness, and symptoms of meningeal irritation. Ophthalmologic symptoms include visual field defects, visual loss, diplopia, and ophthalmoplegia. Endocrinologic disturbances include pituitary adenoma symptoms, cortisol deficiency, panhypopituitarism, diabetes insipidus, and syndrome of inappropriate secretion of antidiuretic hormone. Magnetic resonance imaging is the imaging method of choice to aid the PA diagnosis. Its differential diagnoses include cerebrovascular accidents, infectious diseases, and other causes of endocrinologic imbalance. Transsphenoidal surgery is the treatment of choice, especially if there are associated visual abnormalities and ophthalmoplegia. Clinicians should be aware of the presenting symptoms because early diagnosis may reduce the morbidity and mortality of this neurosurgical emergency.

Isolated clival metastasis: a rare presentation of renal cell carcinoma.

Renal cell carcinoma accounts for 3% of all adult malignancies. Usual sites of metastasis are lymph nodes, lungs, bone, liver and brain. We describe a patient who presented with complaints of holocranial headache and diplopia. MRI of the head showed a clival-based lesion with associated bony erosion. With suspicion of a metastatic lesion, an ultrasonogram of the abdomen was done which showed a left renal mass that enhanced on contrast-enhanced CT. There were no other metastatic foci. Patient underwent radiotherapy for the clival lesion. This case report emphasises on the evaluation of clival lesion with cranial neuropathies for a possibility of a renal primary tumour.

Visual complaints in intracranial germinomas.

OBJECTIVE: Patients with brain tumors often report having visual complaints. This may be due to increased intracranial pressure, compression/invasion of the optic pathway or diplopia. We assessed the incidence and the etiology of visual symptoms in patients with intracranial germinoma tumors (ICGTs). METHODS AND MATERIALS: We performed a blinded retrospective review of the clinical charts and the initial magnetic resonance imaging (MRI) of 28 patients with ICGT. Thirteen tumors were pineal, five suprasellar, seven bifocal, and further three involved either the optic nerve, the corpus callosum, or the brainstem. RESULTS: Twelve patients reported visual disturbances, seven of whom mainly experienced a decrease in vision. Two of those were initially managed as "retrobulbar neuritis" when endocrinologic symptoms prompted assessment by MRI. Involvement of the optic pathway was underestimated, and both relapsed. Field deficits were definitive sequelae, whereas visual acuity was sometimes regressive in the absence of optic atrophy. CONCLUSIONS: Compression or invasion of the optic pathway by germinomas is not a rare occurrence, and this possibility should not be overlooked when thickening or contrast enhancement is detected. Radiotherapy fields should be extended accordingly.

Inferior rectus muscle rupture due to orbital trauma / Ruptura de músculo reto inferior por trauma orbitário

ABSTRACT A 48-year-old patient with blunt periorbital trauma presented with vertical strabismus and diplopia secondary to inferior rectus muscle avulsion. After ophthalmologic and CT scan evaluation, early surgical treatment with anatomical restoration led to improvement in motility deficits with resolution of diplopia.

RESUMO Paciente de 48 anos com história de trauma periorbitário contuso apresentou estrabismo vertical e diplopia secundários à avulsão de músculo reto inferior. Após avaliação oftalmológica e tomográfica, o tratamento precoce cirúrgico das lesões com reparo anatômico permitiu melhora nos deficits de motilidade com resolução da diplopia.

Diplopia: What to Double Check in Radiographic Imaging of Double Vision.

When patients see double with both eyes open, known as "binocular diplopia," this may be a harbinger of underlying life-threatening causes. This article presents pertinent anatomy, critical abnormality, and radiographic features that should be double checked for in diplopia. Key areas requiring a double check using the acronym VISION include Vascular, Infectious and Inflammatory, the Scalp for giant cell arteritis, Sphenoid and Skull base in trauma, Increased intracranial pressure (pseudotumor cerebri), Onset of new headaches or psychosis, and Neoplasm. This article reviews the pertinent abnormalities and radiographic imaging critical to assess in patients with diplopia.