Prognosticators of Visual Acuity After Indirect Traumatic Optic Neuropathy.

BACKGROUND: The purpose of this study is to determine whether there are radiographic and systemic clinical characteristics that can predict final visual outcomes in patients with indirect traumatic optic neuropathy (iTON). METHODS: This study is a retrospective, multicenter case series of adult patients with iTON treated initially at large, urban, and/or academic trauma centers with follow-up at an affiliated ophthalmology clinic. In addition to detailed cranial computed tomography characteristics, demographics, systemic comorbidities, coinjuries, blood products administered, and intracranial pressure, along with other factors, were gathered. LogMAR visual acuity (VA) at the initial presentation to the hospital and up to 12 months follow-up was collected. RESULTS: Twenty patients met inclusion criteria; 16 (80%) were men with a mean age of 40.9 years (±20.9). Mean initial VA was 1.61 logMAR (∼20/800, ± 0.95), and final VA was 1.31 logMAR (∼20/400, ± 1.06). Three patients (4 eyes) had no light perception (NLP) VA at presentation and remained NLP at final follow-up. Of the predictors analyzed, only the initial VA was found to be a significant predictor of visual outcome. The presence of orbital fractures, intraconal and/or extraconal hemorrhage, as well as systemic comorbidities, were not found to significantly affect visual outcome. CONCLUSIONS: After evaluating multiple factors, initial VA was the only factor associated with visual prognosis in iTON. This knowledge may better enable clinicians to predict visual prognosis and set reasonable expectations with patients and families at the time of injury.

A Unique Radiologic Case of Optic Nerve Infarction in a Patient With Mucormycosis.

ABSTRACT: This is a rare presentation of a unilateral optic nerve infarction of the left eye caused by mucormycosis in a 51-year-old man with poorly controlled Type 2 diabetes. Diffusion-weighted MRI of the orbit demonstrated extensive infarction of the left optic nerve with ipsilateral cavernous sinus thrombosis and periorbital adnexal inflammation. Left orbital exenteration and sinus debridement were performed, and mucormycosis involving the optic nerve sheath was confirmed on histopathology.

Orbitocerebral Mucormycosis in a Patient With Central Nervous System Lymphoma.

A 61-year-old man with well-controlled diabetes mellitus type 2, cirrhosis from hepatitis C, alcohol abuse, and portal hypertension presented with painful vision loss and left orbital swelling. Imaging showed diffuse orbital, perineural, and pachymeningeal inflammation. He was initially diagnosed with neurosarcoidosis. However, cerebrospinal fluid analysis revealed central nervous system lymphoma, and lacrimal gland biopsy showed fungal organisms consistent with mucormycosis. The authors describe a case of Mucorales infection lacking sinonasal involvement and discuss the differential diagnosis and management of patients presenting with orbital and central nervous system inflammation from this uncommon fungal infection.

Anatomy and Pathology of the Skull Base: Malignant and Nonmalignant Lesions.

The skull base (SB) is the osseous foundation of the cranial vault. It contains many openings that allow communication between the extracranial and intracranial structures. This communication is crucial in normal physiologic processes yet may also arrow spread of disease. This article provides a comprehensive review of SB anatomy including important landmarks and anatomic variants relevant to SB surgery. We also illustrate the diverse pathologies affecting the SB.

It's Not All in Your Head: Thoracic Manifestations of Neurologic Diseases and Disorders.

Myriad conditions may affect both the neurologic system and the thorax, while other diseases primarily affecting the thorax may manifest with neurologic abnormalities. Correlation of signs, symptoms, and imaging findings in the neurological system with those in the thorax can help diagnose certain conditions and/or guide further diagnostic work-up and treatment. We will review and illustrate the imaging appearance of several systemic/neurological diseases with thoracic manifestations as well as discuss conditions in the thorax that can lead to neurologic symptoms.

Burkitt lymphoma masquerading as Tolosa-Hunt syndrome in an HIV-seropositive patient.

PURPOSE: To describe a rare case of Burkitt lymphoma metastatic to the cavernous sinus that was initially diagnosed as Tolosa-Hunt syndrome. CASE DESCRIPTION: A 31-year-old confirmed and treatment-compliant HIV-positive Hispanic male acutely developed diplopia, ptosis, numbness in the V1 distribution, and complete external ophthalmoplegia in the right eye over 1 week. Imaging showed a mass-like lesion within the right cavernous sinus without other intracranial abnormalities. He was started on broad-spectrum antibiotics and antifungals without improvement. Inflammatory and infectious workup was negative. A presumed diagnosis of Tolosa-Hunt syndrome was made based on clinical and radiographic findings, as well as the absence of another etiology to explain the patient's presentation. He was then started on high-dose oral steroids with improvement of orbital pain only. Shortly after being discharged on steroids, the patient returned to the hospital with severe abdominal pain. Computed tomography of the abdomen showed perforated ileitis with aneurysmal dilation of the ileum and marked wall thickening concerning for a mass lesion. Positron emission tomography-computed tomography showed an uptake in the terminal ileum and right cavernous sinus consistent with metastatic Burkitt lymphoma, matching with pathology. After several cycles of chemotherapy, symptoms improved, and he regained full ocular motility in the affected eye. However, the patient ultimately died due to peritonitis and pyelonephritis. CONCLUSION: Burkitt lymphoma metastatic to the cavernous sinus was diagnosed after an initial diagnosis of Tolosa-Hunt syndrome. Tolosa-Hunt syndrome is a diagnosis of exclusion and should only be made after ruling out other pathologies.

Idiopathic Central Nervous System Inflammatory Disease in the Setting of HLA-B27 Uveitis.

Purpose: The purpose of the article is to describe a novel case of idiopathic central nervous system inflammatory disease with bilateral human leukocyte antigen (HLA)-B27-positive anterior uveitis. Methods/Results: A 15-year-old African American boy with bilateral HLA-B27-positive anterior uveitis controlled with topical and oral steroids for 8 months acutely developed headaches, left eyelid ptosis, and binocular diplopia. Imaging showed lesions in the right midbrain, superior colliculus, cerebellar peduncles, and cerebellar vermis and leptomeningeal enhancement along the vermian foliae. Cerebral spinal fluid tests showed mild lymphohistiocytic pleocytosis with negative cytology; inflammatory and infectious workup were negative. He received intravenous methylprednisolone without initial symptomatic improvement; repeat magnetic resonance imaging (MRI) showed reduced lesion burden. Oral steroids were continued; his symptoms resolved in 1 month. Repeat MRI 2 months after presentation showed almost complete lesion resolution. Conclusions: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) was diagnosed. HLA-B27 positivity may represent a novel association with CLIPPERS.

Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology.

OBJECTIVE: The objective was to evaluate the sensitivity and specificity of computed tomography (CT) diagnosis of open globes, determine which imaging factors are most predictive of open globe injuries, and evaluate the agreement between neuroradiologist and ophthalmologist readers for diagnosis of open and closed globes. METHODS: This study was a retrospective cohort study. Patients who presented to Memorial Hermann-Texas Medical Center with suspicion for open globes were reviewed. One neuroradiologist and two ophthalmologists masked to clinical information reviewed CT images for signs concerning for open globe including change in globe contour, anterior chamber deformation, intraocular air, vitreous hemorrhage, subretinal fluid indicating retinal or choroidal detachment, dislocated or absent lens, intraocular foreign body, and orbital fracture. Using the clinically or surgically confirmed globe status as the true globe status, sensitivity, specificity, and agreement (kappa) were calculated and used to investigate which imaging factors are most predictive of open globe injuries. RESULTS: A total of 114 patients were included: 35 patients with open globes and 79 patients with closed globes. Specificity was greater than 97% for each reader, and sensitivity ranged from 51% to 77% among readers. The imaging characteristics most consistently used to predict an open globe injury were change in globe contour and vitreous hemorrhage (sensitivity = 43% to 57%, specificity > 98%). The agreement of impression of open globe between the neuroradiologist and ophthalmologists was good and excellent between ophthalmologists. CONCLUSIONS: Computed tomography imaging is not absolute, and the sensitivity is still inadequate to be fully relied upon. The CT imaging findings most predictive of an open globe injury were change in globe contour and vitreous hemorrhage. Clinical examination or surgical exploration remains the most important component in evaluating for a suspected open globe, with CT imaging as an adjunct.

Magnetic resonance imaging (MRI) in the diagnosis of head and neck disease.

Magnetic resonance imaging (MRI) is the modality of choice to identify intracranial or perineural spread from a head and neck primary tumor. Perineural spread is a form of metastatic disease in which primary tumors spread along neural pathways. Orbital cellulitis is a sight-threatening, and potentially life-threatening condition. Urgent imaging is performed to assess the anatomic extent of disease, including postseptal, cavernous sinus, and intracranial involvement, and identify orbital abscesses that require exploration and drainage. MRI is useful in the evaluation of the brachial plexus.