Rapid progression from trochlear nerve palsy to orbital apex syndrome as an initial presentation of advanced gastric cancer / 영남의대학술지

The most cases with orbital metastases have been reported in patients with a prior established diagnosis of cancer and widespread systemic involvement. However, ocular symptoms can be developed as an initial presentation of cancer in patients without cancer history. We report a case of rapid progression from trochlear nerve palsy to orbital apex syndrome as an initial presentation of advanced gastric cancer.

Análisis semántico y gramatical de los términos latinos de los ramos terminales del nervio nasociliar / Semantic and grammatical analysis of latin terms of the terminal branches of the nasociliary nerve

RESUMEN: La necesidad de unificar criterios respecto a los nombres de las estructuras anatómicas ha sido una permanente preocupación de los anatomistas del mundo, de tal manera que a partir de 1895 se inicia un proceso de estandarización y normalización de la terminología anatómica mundial. Se publica la Nomina Anatomica tratando de nominar las estructuras con un solo nombre en latín y se suprime los epónimos y homónimos. En la actualidad la Terminologia Anatomica sustituye a la Nomina Anatomica, con las mismas características, pero con la adición del término en el idioma de cada país. Sin embargo, persisten algunos errores desde la elaboración de la Nomina Anatomica y que se mantienen en Terminologia Anatomica, derivados tanto de la estructura gramatical latina, principalmente en el número y género, así como de la descripción de algunas estructuras anatómicas. Este es el caso de los ramos del nervio nasociliar, específicamente del ramo etmoidal anterior y del ramo infratroclear. Para el efecto se realizó una revisión de la descripción del nervio nasociliar y sus ramos terminales, se compararon entre sí y con los nombres que aparecen en la Terminologia Anatomica, para verificar que tanto la descripción como la construcción gramatical latina sean correctas. Se encontraron errores en la estructuración gramatical y jerárquica del ramo nasal interno, así como la supresión de los ramos palpebrales superior e inferior del nervio infratroclear, por lo que proponemos el cambio del término codificado con A14.2.01.031 a Ramus nasalis internus y la adición de los nombres Ramus palpebralis superior y Ramus palpebralis inferior.

SUMMARY: The need to unify criteria regarding the names of anatomical structures has been a permanent concern of anatomists worldwide. Therefore, and beginning in 1895 a standardization and normalization process of world anatomical terminology was initiated. The Nomina Anatomica is published in an attempt to name the structures with a single name in Latin and the eponyms and homonyms are deleted. Today the Terminologia Anatomica replaces the Nomina Anatomica, with the same characteristics, but with the addition of the term in the language of each country. Nevertheless, some errors persist from the Nomina Anatomica that remain in Terminologia Anatomica, derived from both the Latin grammatical structure, mainly in the number and gender, as well as the description of some anatomical structures. This is the case of the nasociliary nerve branches, specifically the anterior ethmoidal branch and the infratroclear branch. For this purpose, a review of the description of the nasociliary nerve and its terminal branches was made, they were compared between each other, and with the names that appear in the Terminologia Anatomica, to verify that both the description and the Latin grammatical construction are correct. Errors were found in the grammatical and hierarchical structure of the internal nasal branch, as well as the suppression of the upper and lower palpebral branches of the infratrochlear nerve. Therefore, we propose the change of the coded term with A14.2.01.031 to "Ramus nasalis internus" and the addition of the names "Ramus palpebralis superior" and "Ramus palpebralis inferior".

Trochlear Nerve Palsy Caused by Quadrigeminal Cistern Lipoma

PURPOSE: To report a case of trochlear nerve palsy caused by quadrigeminal cistern lipoma located in the dorsal midbrain. CASE SUMMARY: A 65-year-old male visited our clinic for intermittent vertical diplopia over 2-year period. Symptoms of diplopia had worsened over the past two weeks. He had no previous medical history except having had diabetes for 1 month. The best-corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. Pupillary examination was not remarkable. Extraocular examination showed 4 prism diopters (PD) left hypertropia at distant gaze and 4 PD exotropia at near gaze, with adduction elevation of the left eye. The Bielschowsky head tilt test revealed 6 PD left hypertropia on the left gaze and orthotropia on the right tilt. Fundus examination showed excyclotorsion of the right eye and incyclotorsion of the left eye. Brain magnetic resonance imaging revealed quadrigeminal cistern lipoma. Prism glasses were prescribed to alleviate diplopia, and we followed up the lesions without further treatment. CONCLUSIONS: Trochlear nerve palsy can be caused by quadrigeminal cistern lipoma; however, it is uncommon for this condition to be caused by a compressive lesion. Prompt neuroimaging can be helpful to rule out the causes of this condition in patients with atypical symptoms.

Delayed Trochlear Nerve Palsy Following Traumatic Subarachnoid Hemorrhage: Usefulness of High-Resolution Three Dimensional Magnetic Resonance Imaging and Unusual Course of the Nerve / 대한신경손상학회지

Cranial nerve palsies are relatively common after trauma, but trochlear nerve palsy is relatively uncommon. Although traumatic trochlear nerve palsy is easy to diagnose clinically because of extraocular movement disturbances, radiologic evaluations of this condition are difficult to perform because of the nerve's small size. Here, we report the case of a patient with delayed traumatic trochlear nerve palsy associated with a traumatic subarachnoid hemorrhage (SAH) and the related radiological findings, as obtained with high-resolution three-dimensional (3D) magnetic resonance imaging (MRI). A 63-year-old woman was brought to the emergency room after a minor head trauma. Neurologic examinations did not reveal any focal neurologic deficits. Brain computed tomography showed a traumatic SAH at the left ambient cistern. The patient complained of vertical diplopia at 3 days post-trauma. Ophthalmologic evaluations revealed trochlear nerve palsy on the left side. High-resolution 3D MRI, performed 20 days post-trauma, revealed continuity of the trochlear nerve and its abutted course by the posterior cerebral artery branch at the brain stem. Chemical irritation due to the SAH and the abutting nerve course were considered causative factors. The trochlear nerve palsy completely resolved during follow-up. This case shows the usefulness of high-resolution 3D MRI for evaluating trochlear nerve palsy.

Superior Oblique Myokymia Associated with Neurovascular Cross Compression

Superior oblique myokymia (SOM) is a rare disorder characterized by unilateral paroxysmal oscillopsia or diplopia. Recent studies revealed that SOM can be associated with neuro-vascular cross compression (NVCC) of the trunk of the trochlear nerve. Although it frequently occurs without any underlying systemic disease or concurrent neurologic sign, we need to consider this NVCC especially in cases with persistent disturbing symptoms. Hereby, we present two cases of SOM whose neuroimaging studies suggest NVCCs and, discuss recent update of the pathomechanism of SOM.

Trochlear Nerve Schwannoma: Case Report and Literature Review

Schwannomas arise from the Schwann cells of the peripheral and cranial nerves. They represent 8% of the primary cerebral neoplasms. Although schwannomas usually develop in sensory nerves, most often on the vestibular and trigeminal nerves, in very rare cases they can develop in motor nerves. We reported an unusual case of a 29-year-old woman with headache, nausea, vomiting, and blurred vision ongoing for 3 years. Magnetic resonance of the brain showed a solid-cystic expanded injury, heterogeneous, with limits partially defined and epicenter on the pineal gland. The lesion presented hyposignal in T1 and isosignal in T2. An intense enhancement of the solid part was observed after contrast injection. Foci of calcification and absence of diffusion restriction were also observed. The patient underwent microneurosurgery with supracerebellar infratentorial approach in a seated position. Subtotal resection was performed with maintenance of calcified tumor tissue adhered to the right Rosenthal basal vein. In the postoperative phase, the patient remained with diplopia when looking down; however, she reported improvement of headache and nausea.

Os schwannomas surgem das células de Schwann, dos nervos periféricos e cranianos e representam 8% das neoplasias cerebrais primárias. Apesar de os schwannomas se desenvolverem comumente em nervos sensoriais, mais frequentemente no nervo vestibular e trigêmeo, em casos muito raros ele pode se desenvolver em nervos motores. Relatamos um caso raro, de uma paciente do sexo feminino, 29 anos, com quadro de cefaleia, náuseas, vômitos e turvação visual há três anos. Ressonância magnética de encéfalo demonstrou lesão expansiva sólido-cística, heterogênea, com limites parcialmente definidos e epicentro na glândula pineal. Apresentou hipossinal em T1 e isossinal em T2. Houve intenso realce da parte sólida após injeção de contraste. Foram observados focos de calcificação e ausência de restrição à difusão. A paciente foi submetida a tratamento microneurocirúrgico com acesso infratentorial supracerebelar em posição sentada. Houve ressecção subtotal com manutenção de tecido tumoral calcificado aderido a veia basal de Rosenthal direita. No pós-operatório, a paciente permaneceu com diplopia na mirada ocular para baixo, entretanto apresentou melhora de cefaleia e náuseas.

Isolated Left Trochlear Nerve Palsy Caused by Sphenoid Sinus Mucocele / 대한이비인후과학회지

Paranasal sinus mucoceles are an uncommon cause of isolated palsies of cranial nerves III, IV, and VI. The trochlear nerve has been reported to be less frequently affected than the abducens and oculomotor nerves. Isolated sphenoid sinus diseases may cause serious complications by involving adjacent vital structures such as the optic nerve, cavernous sinus, internal carotid artery, and cranial nerves III–VI. We report a case of a 76-year-old woman who presented to our emergency department with a chief complaint of acute double vision and headache. Her diplopia was diagnosed as left trochlear nerve palsy. Brain CT and MRI revealed expanding cystic lesions in both sphenoid sinuses with bony erosion of the left sinus wall. The patient underwent an endoscopic intranasal sphenoidotomy and recovered completely from diplopia at postoperative 2 months. The relationship between the trochlear nerve palsy and its anatomy is also discussed.

A Case of Trochlear Nerve Schwannoma Presenting with Binocular Diplopia

PURPOSE: To report a case of unilateral trochlear nerve schwannoma in a patient without neurofibromatosis. CASE SUMMARY: A 58-year-old male presented with acute onset of diplopia which developed 10 days prior. Alternate prism cover test, ductions and versions and Bielschowsky three-step test were compatible with left superior oblique muscle palsy. High-resolution magnetic resonance imaging showed a 6-mm-sized lobulated mass in the cisternal segment of the left trochlear nerve passing lateral to the brainstem. An additional thin-section gadolinium-enhanced orbit magnetic resonance imaging showed definite enhancement in the entire portion of the lobulated mass, compatible with a trochlear nerve schwannoma. Diplopia was managed conservatively with prism glasses and regular follow-up examinations were recommended without further treatment. CONCLUSIONS: A trochlear nerve tumor should be considered in adults who develop diplopia associated with acquired superior oblique muscle palsy.

Fratura intra-articular da extremidade distal do úmero tipo IV de Bryan e Morrey tratada cirurgicamente com acesso anterior: relato de caso / Bryan and Morrey type IV intra-articular fracture of the distal extremity of the humerus treated surgically with anterior access: case report

No contexto dos traumatismos ao nível do cotovelo, as fraturas com traço coronal da extremidade distal do úmero são raras e resultam de trauma axial indireto no membro superior estendido. São fraturas intra-articulares de difícil tratamento por demandar redução anatômica e estável para a manutenção da congruência articular e redução das complicações como rigidez. Reporta-se neste artigo um caso ocorrido em um jovem do sexo masculino, vítima de queda de escada que resultou em uma fratura intra-articular do úmero distal tipo IV de Bryan e Morrey e que foi submetido a tratamento cirúrgico por via de acesso anterior e osteossíntese com dois parafusos de Herbert inseridos de anterior para posterior.

Within the context of elbow-level trauma, fractures with a coronal line at the distal extremity of the humerus are rare and result from indirect axial trauma with the arm extended. These are difficult-to-treat intra-articular fractures, since they require stable anatomical reduction in order to maintain joint congruence and diminish complications such as stiffness. This paper reports a case that occurred in a young man who suffered a fall from a ladder that resulted in a Bryan and Morrey type IV intra-articular fracture of the humerus. The injury was treated surgically by means of an anterior access, using osteosynthesis with two Herbert screws that were inserted from anterior to posterior.

Skew deviation e ocular tilt reaction versus paralisia do nervo troclear / Skew deviation and ocular tilt reaction versus trochlear nerve palsy

Skew deviation é o desalinhamento vertical dos olhos causado por disfunção unilateral no tronco cerebral, cerebelo ou sistema vestibular periférico, comprometendo as vias por onde transitam impulsos dos órgãos otolíticos aos núcleos oculomotores. Está frequentemente associado a torção ocular e inclinação da cabeça, compondo, assim, a ocular tilt reaction. Neste artigo os autores ressaltam aspectos históricos, fisiológicos, etiopatogênicos e clínicos que contribuem para caracterizar ambas as condições, além da diferenciação clínica com a paralisia do nervo troclear.

Skew deviation is the vertical misalignment of the eyes caused by unilateral dysfunction in the brain stem, cerebellum or peripheral vestibular system, resulting imbalance in otolith input to the oculo-motor system. It's often associated with ocular torsion and head tilt, which together comprise the ocular tilt reaction. In this article the authors emphasize the historical, physiological, etiopathogenesis and clinical aspects that contribute to characterize both conditions, and help to differentiate them clinically from trochlear nerve palsy.

A Case of Bilateral Trochlear Nerve Palsy Following Cisternography

PURPOSE: To report a case of bilateral trochlear nerve palsy following cisternography. CASE SUMMARY: A 43-year-old male with intermittent watery rhinorrhea persisting for 3 months visited the neurosurgery department of our institute. His past medical history included removal of a pituitary adenoma 22 years prior to presentation. Cerebrospinal fluid leakage was suspected and cisternography was performed. The patient was referred to our ophthalmology department for diplopia 3 days after the cisternography. An alternate prism cover test showed 5 prism diopter (PD) right hypertrophia in the primary position, and underaction of bilateral superior oblique muscles and overaction of the left inferior oblique muscle. A positive Bielschowsky test with the head tilted to either side was observed and excyclotorsion was 9degrees on the double Maddox rod test. The patient was diagnosed with bilateral trochlear nerve palsy. After 2 years of follow-up, diplopia persisted and recession of the bilateral inferior oblique muscles was performed. After the surgery, diplopia disappeared, the fundus photography showed no excyclotorsion, and the double Maddox rod test indicated 3degrees of excyclotorsion. CONCLUSIONS: Cisternography should be carefully performed due to the possibility of bilateral trochlear nerve palsy, an extremely rare but possible occurrence following the procedure.

A Case of Pituitary Metastasis of Lung Cancer Presenting as Cavernous Sinus Syndrome / 대한이비인후과학회지

The cavernous sinus contains significant structures such as the internal carotid artery and cranial nerves III to VI. Cavernous sinus lesions may cause ophthalmoplegia, proptosis, and diplopia. We report a 56-year-old woman who presented with throbbing headache and associated right-sided ocular pain. While awaiting imaging studies, she suddenly developed opthalmoplegia and ptosis of the right eye. She had ipsilateral palsy of the third and fourth cranial nerves, while the sixth nerve remained intact. Magnetic resonance imaging revealed a pituitary gland mass extending into the right cavernous sinus with associated sphenoid sinusitis. The patient underwent endoscopic sinus surgery and subsequent pituitary tumor removal by transsphenoidal approach. During preoperative evaluation, a mass was found protruding in her left bronchus. The pituitary tumor pathologic examination revealed metastatic adenocarcinoma of the lung. In this patient, the initial symptoms of lung cancer were headache and cavernous sinus syndrome, which had metastasized to the pituitary gland.

Occurrence of Trochlear Nerve Palsy after Epiduroscopic Laser Discectomy and Neural Decompression

Epiduroscopic laser discectomy and neural decompression (ELND) is known as an effective treatment for intractable lumbar pain and radiating pain which develop after lumbar surgery, as well as for herniation of the intervertebral disk and spinal stenosis. However, various complications occur due to the invasiveness of this procedure and epidural adhesion, and rarely, cranial nerve damage can occur due to increased intracranial pressure. Here, the authors report case in which double vision occurred after epiduroscopic laser discectomy and neural decompression in a patient with failed back surgery syndrome (FBSS).

A Case of Herpes Zoster Ophthalmicus with Isolated Trochlear Nerve Involvement

BACKGROUND: Herpes zoster ophthalmicus (HZO) can involve the oculomotor nerve; however, isolated trochlear nerve palsy has rarely been reported. CASE REPORT: An 83-year-old man who suffered from HZO in the right frontal area and scalp subsequently developed vertical diplopia and severe pain. Cerebrospinal fluid examination and brain MRI revealed no abnormalities. Isolated right trochlear nerve palsy was diagnosed based on the findings of neuro-ophthalmological tests. CONCLUSIONS: Isolated trochlear nerve involvement associated with HZO is very rare and may be easily overlooked. Physicians should carefully examine oculomotor involvement in HZO.

Isolated, Contralateral Trochlear Nerve Palsy Associated with a Ruptured Right Posterior Communicating Artery Aneurysm

Trochlear nerve palsy associated with spontaneous subarachnoid hemorrhage (SAH) is known to be a rare malady. We report here on a patient who suffered with left trochlear nerve palsy following rupture of a right posterior communicating artery aneurysm. A 56-year-woman visited our emergency department with stuporous mental change. Her Hunt-and-Hess grade was 3 and the Fisher grade was 4. Cerebral angiography revealed a ruptured aneurysm of the right posterior communicating artery. The aneurysm was clipped via a right pterional approach on the day of admission. The patient complained of diplopia when she gazed to the left side, and the ophthalmologist found limited left inferolateral side gazing due to left superior oblique muscle palsy on day 3. Elevated intracranial pressure, intraventricular hemorrhage or a dense clot in the basal cisterns might have caused this trochlear nerve palsy.

A Case of Neurosyphilis with Acute Optic Neuritis and Trochlear Nerve Palsy in Human Immunodeficiency Virus Infected Male / 감염과화학요법

With the increase in human immunodeficiency virus (HIV) infection, the incidence of syphilis also increased worldwide presenting with diverse clinical manifestations. We experienced a case of symptomatic early neurosyphilis manifesting as optic neuritis and trochlear nerve palsy with typical skin lesions of secondary syphilis in an HIV-Infected patient. Intravenous penicillin and oral steroid were administered for 2 weeks. Skin lesions improved after a week, and ocular lesions resolved completely after eight weeks of treatment.

A Case of Orbital Apex Syndrome Related to Sphenoid Fungal Sinusitis / 대한이비인후과학회지

Orbital apex syndrome (OAS) has been described previously as a syndrome involving damage to the oculomotor nerve, trochlear nerve, abducens nerve, and ophthalmic branch of the trigeminal nerve in association with optic nerve dysfunction. The conditions and symptoms of OAS are characterized by blindness, fixed dilated pupils, proptosis, ptosis of the eye and ophthalmoplegia. Infectious diseases involving the central nervous system, paranasal sinuses, and periorbital structures may lead to an OAS. We recently experienced a rare case of sphenoidal aspergillosis, which damaged the adjacent cavernous sinus structures and led to the definite symptom of OAS in a 75 year-old female. We present this rare case with a brief review of these disease's entities.

Anatomic study of supratrochlear artery and its application in nasal reconstruction / 中华整形外科杂志

<p><b>OBJECTIVE</b>To study the anatomy of the cutaneous branch (CB) of supratrochlear artery and its relevance to the design of frontal flap in nasal reconstruction.</p><p><b>METHODS</b>10 fresh cadavers were dissected to study the position and course of the CB of supratrochlear artery (supraorbital rim and facial midline as landmark). The communication between the CB and supraorbital artery was also studied. 5 cases of ultra-thin frontal flaps and 11 cases of bi-flap( cutaneous flap and muscular flap) were designed on anatomic basis. The survival rate of flap, the stability and aesthetic appearance of the reconstructed nose were followed up.</p><p><b>RESULTS</b>The supratrochlear artery gave off constant CB (1.18 +/- 0.36) cm from upper orbital rim and (1.35 +/- 0.34) cm from the midline of face. The CB passed in a subcutaneous plane and communicated with the bilateral muscular branch, CB of the opposite side and bilateral supraorbital artery. The supratrochlear artery only had CB with no muscular branch in 3 cases. All the flaps survived completely except one with blister on the nose tip which healed spontaneously. The postoperative aesthetic appearance was very satisfactory.</p><p><b>CONCLUSIONS</b>The supratrochlear artery has constant CB. The frontal ultra-thin flap pedicled with the CB can improve the therapeutic effect of nasal reconstruction.</p>

Right Superior Oblique Paralysis associated with Idopathic Hypertropic Cranial Pachymeningitis

PURPOSE: Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare disase, which causes chronic progressive inflammation and thickening of the basal dura mater. We report a case of IHCP associated with superior oblique paralysis and present a review of the literature. METHODS: An 8-year-old boy presented with binocular diplopia and left side head tilting. Suspecting right superior oblique muscle paralysis, an alternating prism test, head tilt test, fundus examinations, neurologic examination, and brain MRI were performed. RESULTS: The brain MRI revealed abnormal enhancement of the right tentorium in the course of the right fourth cranial nerve, leading to a diagnosis of IHCP with paralytic strabismus and the patient was treated with systemic steroid therapy. CONCLUSIONS: We report a case of IHCP with right superior oblique paralysis. Patients with recent onset paralytic strabismus require appropriate neurolgic and neuroimaging examinations.

Combined Facial and Contralateral Trochlear Nerve Palsy in a Patient with Diabetes Mellitus

There is an increasing number of reports that the lesion site in isolated cranial neuropathies may be the brainstem. The authors describe a diabetic patient with peripheral type facial palsy and concurrent trochlear palsy. Magnetic resonance imaging showed only a small pontine infarction responsible for the facial palsy. Multiple cranial nerve palsies seen in this patient might be a manifestation of multiple acute small infarcts involving both the brainstem and its cranial nerve root simultaneously.