Successful surgical treatment of oculomotor palsy due to schwannoma of the cavernous sinus in a 7-year-old girl: a case report.

Oculomotor nerve schwannoma in children not associated with neurofibromatosis is a rare disease, with 26 pediatric cases reported so far. There is no established treatment plan. A 7-year-old girl presented with oculomotor nerve palsy. Surgical reduction of the tumor combined with postoperative gamma knife surgery preserved the oculomotor nerve, improved oculomotor nerve function, and achieved tumor control during the observation period of 20 months. The combination of partial surgical resection and gamma knife surgery as a treatment strategy for oculomotor nerve schwannoma resulted in a good outcome.

Oculomotor nerve cavernous malformation: case report and operative video.

BACKGROUND: Cavernous malformations (CMs) are clusters of thin-walled sinusoidal vessels without well-defined walls. Though they can occur anywhere in the neuroaxis, cranial nerve (CN) CMs are rare. METHOD: We report a 47-year-old male with gradual CN III palsy. Initial imaging showed no significant findings, but a follow-up MRI revealed a growing lesion along CN III. Intraoperative findings confirmed a CN III CM. Diagnosing and treating CN III CM are complex. Radiological findings lack specificity, requiring consideration of various diagnoses for patients with isolated CN III palsy and abnormal radiological findings. CONCLUSION: Surgery is the gold standard, aiming for complete lesion removal while minimizing neurological complications.

Split-Tendon Medial Transposition of Lateral Rectus for Pediatric Complete Oculomotor Palsy.

BACKGROUND: Split-tendon medial transposition of lateral rectus (STMTLR) for complete oculomotor palsy can correct large angles of exotropia in adults, but outcomes are variable, and complications are frequent. Only a few pediatric cases have been reported, and further insight is needed to assess the child's alignment outcomes and ability for postsurgical gain of function. The aim of our study is to report the outcomes of this surgical procedure in pediatric cases of complete oculomotor palsy. METHODS: A retrospective review of outcomes was conducted on 5 consecutive patients with complete oculomotor palsy treated with STMTLR by a single surgeon (V.S.S.) between 2015 and 2021 at tertiary referral centers. Primary outcome was postoperative horizontal alignment, and secondary outcome was demonstration of gain-of-function activity in the field of action of the paretic medial rectus muscle. RESULTS: Five cases of pediatric complete oculomotor palsy underwent surgical treatment with STMTLR. Subjects averaged 5.3 years old (range 10 months-16 years). Two were female. Etiologies were heterogeneous, and all presented with unilateral (n = 2) or bilateral complete oculomotor palsy with exodeviations ranging from 45 to >120 prism diopters. Two subjects had bilateral disease secondary to military tuberculosis with CNS involvement. A third subject presented iatrogenically with complete bilateral third nerve palsies secondary to removal of a nongerminomatous germ cell tumor (NGGCT) of the pineal gland. The 2 remaining subjects had monocular involvement in their right eye, 1 from compressive neuropathy after a cavernoma midbrain hemorrhage, and 1 from a congenital right oculomotor palsy. All patients were observed to have stable ocular alignment for a period of at least 6 months before surgery. Unilateral STMTLR was performed in all cases except the subject with NGGCT, in which bilateral STMTLR was performed. Measurement of alignment permanence out to 1-3 years postop resulted in an average correction of 40.83 prism diopters (range 37.5-45 prism diopters) per operated eye. Four of 5 subjects regained limited but active adduction eye movements, and the 2 unilateral cases demonstrated improved convergence. None of the subjects experienced significant complications. CONCLUSIONS: STMTLR was a safe and effective approach for the surgical correction of complete pediatric oculomotor palsy in our case series. In addition, pediatric patients may benefit from STMTLR with immediate gain-of-function activity in the transposed lateral rectus muscle, which supports the hypothesis that children have a dynamic and adaptive neuroplasticity of visual target selection that predominates established agonist/antagonist neural signaling.

Glioblastoma multiforme with oculomotor nerve involvement: case report and literature review.

Gliomas involving the cranial nerves III-XIII are rare. Even rarer are glioblastomas multiforme (GBMs) with only 10 cases previously reported. Oculomotor nerve involvement was described in only 2 patients. The mechanisms proposed so far include an origin from the nerve itself or an extension within the nerve of a midbrain tumor. We report the case of a 69-year-old man who presented with an isolated left oculomotor nerve palsy. He was found to have a left temporal GBM extended to the frontal lobe. Diagnostics and intraoperative and pathological findings clearly demonstrated a massive infiltration of the cisternal portion of the left oculomotor nerve. We suppose this could be the first case of direct oculomotor nerve invasion by exophytic spread of a supratentorial GBM or by subarachnoid seeding from a temporal tumor. Less probably, it could be the first case of an oculomotor nerve GBM with a temporal lobe invasion.

Posterior communicating artery infundibulum with oculomotor nerve palsy treated with microvascular decompression: a case report and 2-dimensional technical operative video.

Oculomotor nerve palsies are typically associated with posterior communicating artery (PcommA) aneurysms. We report a rare case of an oculomotor nerve palsy caused by a PcommA infundibular dilatation. Although there are cases of infundibular dilatations causing cranial nerve palsies, only reports of three involving the PcommA exists. We review these reported cases in the literature and discuss their treatments as well as other non-aneurysmal compressive etiologies that may cause oculomotor nerve palsies. We present the case of a 53-year-old female with transient oculomotor nerve palsy that was initially diagnosed with a PcommA aneurysm. She underwent a craniotomy with plans of microsurgical clipping; however, the dilatation was identified correctly as an infundibulum intraoperatively. The operation was completed as a microvascular decompression and her oculomotor nerve palsy has not returned at the 1-year follow-up. We provide a detailed microsurgical report and video detailing the operative technique and relevant anatomy for this operation. Although rare and not as life-threatening as aneurysms, infundibular dilatations as a cause of oculomotor nerve palsy should remain as a differential diagnosis. Given the difference in natural history and treatment of these two entities, it is important to diagnose and treat them appropriately. Multimodal imaging such as thin-sliced computed tomography angiogram (CTA) and 3-dimensional (3D) rotational angiography can aid in diagnosis.

Early Recurrence of an Infantile Endodermal Oculomotor Nerve Cyst following Surgical Fenestration: A Case Report.

INTRODUCTION: Infantile endodermal oculomotor nerve cyst (EONC) is an extremely rare entity. There are very few pediatric cases reported in the literature, and as expected, oculomotor palsy is the most common presenting symptom. To date however, the risk of recurrence of these lesions following surgical intervention is unclear due to a lack of long-term radiological follow-up. CASE PRESENTATION: We present a case of a 13-month-old male patient with an EONC and detail his surgical fenestration and postoperative course. Somewhat surprisingly, re-expansion occurred within 6 months and remained stable 2 years later. DISCUSSION: A surgical approach to fenestration of an EONC in an infant is possible and should be performed by an expert neurosurgeon. Early recurrence is underreported in the current literature, and we encourage longer term radiological surveillance of these lesions after surgery to optimize primary and recurrent management in the future.

Splitting of the lateral rectus muscle with medial transposition to treat oculomotor palsy: a retrospective analysis of 29 consecutive cases.

PURPOSE: The lateralis splitting technique has been an interesting option for treating large-angle exotropia due to complete 3rd nerve paralysis since its inception in the early 1990s. The purpose of this study is to report on our experience regarding the effectiveness and complications of this method. METHODS: Retrospective analysis of a consecutive series of 29 patients operated by one single experienced surgeon and examined according to a specific operative and perioperative protocol. Patients were examined preoperatively, on the 2nd day and 3rd month after surgery. Outcome measures include strabismus angle, horizontal motility, head turn, binocular function, and incidence and resolution of postoperative serous retinal detachment as seen with infrared imaging and spectral domain optical coherence tomography (SD-OCT). RESULTS: Surgery brought about a large and stable reduction of strabismus angle and head turn. It reduced horizontal motility, but moved the range of monocular excursion much closer to center. Eighty percent of patients with constant diplopia acquired some fields of single binocular vision. A significant number of cases (33.3%) developed transitory serous retinal detachment with varying onset and extent. CONCLUSION: This is by far the largest published study regarding the outcome of lateralis splitting in NIII palsy. The procedure is difficult, yet a very useful option. Serous detachment is a serious complication, but usually transitory. Its cause and mechanisms are not fully understood and warrant further investigation.

Congenital Multiple Ocular Motor Nerve Palsy Complicated by Splitting of the Lateral Rectus Muscle.

We report a case of congenital multiple ocular motor nerve palsy combined with splitting of the lateral rectus muscle (LR). A 59-year-old Japanese female was investigated for worsening esotropia after corrective surgery. She presented with left hypertropia (35Δ) and esotropia (45-50Δ). Orbital magnetic resonance imaging (MRI) showed reduced belly sizes in the superior rectus, inferior rectus, and superior oblique muscles and splitting of the LR, extending from the origin to the belly, in the left eye. Splitting of the LR belly was detected on MRI in a case of congenital multiple ocular motor nerve palsy.

Efficacy of endovascular intervention in patients with unruptured posterior communicating artery aneurysm-related oculomotor nerve palsy.

OBJECTIVES: Oculomotor nerve palsy (ONP) is commonly encountered in daily neurosurgical activities. The ONP secondary to un-ruptured PComA aneurysm might be a unique entity that was different in diagnosis, treatment and prognosis from its ruptured counterparts. Perhaps as a result of the limitation in sample size, studies that solely focused on factors affecting recovery of ONP in patients with unruptured corresponding PComA aneurysms were scarce. METHODS: In this study, we would like to report a relatively larger case series of patients with un-ruptured PComA aneurysm-related ONP. A retrospective review of medical records of 39 patients with un-ruptured PComA aneurysm-related ONP was performed with endovascular coiling. RESULTS: All 39 consecutive patients underwent endovascular coiling. Eighteen (46%) patients had a complete resolution of ONP, 14 (36%) patients had a partial resolution. Time interval from onset of ONP to endovascular intervention (P=0.004), degree of ONP (P=0.015) and age (P=0.016) were predictors of ONP recovery with statistical significance. Sex, aneurysm size and risk factor exposure (smoking, alcohol abuse and hypertension) were not associated with ONP outcomes. CONCLUSION: ONP secondary to un-ruptured aneurysm should be treated as a unique entity from its ruptured counterparts. A prospective study that contains surgical clipping and endovascular coiling, and comparison between two treatment modalities would be more convincing and is anticipated.

Transcaruncular rectus tendon fixation to the orbit and frontalis flap for complete third nerve palsy.

PURPOSE: To describe our experience and outcomes managing complete third cranial nerve palsy. METHODS: This was a retrospective analysis of the clinical records of 7 consecutive patients treated at our centre for unilateral third nerve palsy over the period 2010-2016. We describe our surgical approach using a frontalis muscle flap to correct the eyelid ptosis associated with medial fixation of the rectus muscle tendon to the orbit to correct the horizontal deviation. RESULTS: The seven patients, four women and three men, were of mean age of 44 ± 19 years [18-75 years]. Follow up was 29 ± 31 months [5-82 months]. In the preoperative exam, exotropia in prism diopters (PD) was -70 ± -28 PD [-30 to -90 PD]. At the end of follow up, this was reduced to -11 ± -14 PD [0 to -30 PD]. Preoperative marginal reflex distance 1 (MRD1) was -4 ± 1 mm [-3 to -5 mm] and palpebral fissure height (PFH) was 0.5 ± 1 mm [0-2 mm]. Surgical undercorrection was the target in all patients due to the absent or poor Bell's phenomenon. At the end of follow up, MRD1 was 2.5 ± 0.5 mm [2-3 mm] and PFH was 7 ± 1 mm [6-8 mm]. Cosmetic and functional results were good in all patients. CONCLUSIONS: Medial fixation of the rectus muscle tendon to the orbit associated with a frontalis muscle flap is a valid option for the treatment of exotropia and ptosis in patients with third cranial nerve palsy.

Simplified approach of Gokyigit's technique for complete cranial nerve third palsy.

PURPOSE: To evaluate a simpler approach of the medial transposition of split lateral rectus technique in patients with complete third nerve palsy. METHODS: All eyes with complet third nerve palsy were followed in our Strabismus Department between 2014 and 2016. All patients had complete oculamotor nerve palsy. All patients assed routine ophthalmologic examination. Also the ocular deviation, horizontal and vertical ocular alignments were measured at 6 m and at 1/3 m using the Krimsky corneal reflection test and alternate prism cover test with best optical correction. Same surgeon (BG) performed all procedures in general anesthesia. In this procedure, same Gokyigit's technique except upper and lower part of lateral rectus muscle was passed under the superior oblique tendon and inferior oblique tendon. Final deviation from 0 to 14 PD was considered a successful result. RESULTS: Eight patients were included in the study. The average ages were 39.4 years and male to female ratio 5:3. Patients had a preoperative horizontal deviation - 42.5 ± 2.7 PD and postoperative horizontal deviation - 1.7 ± 2.6 PD. All patients follow-up time were at least 6 months. CONCLUSIONS: Achieved to acceptable alignment in primary position, manage to diplopia and cosmetical appearance are the main aims of patients with third nerve palsy.

Delayed Onset Cranial Nerve Palsies After Endovascular Coil Embolization of Direct Carotid-Cavernous Fistulas.

BACKGROUND: Late recurrence of visual symptoms associated with carotid-cavernous fistula (CCF), including diplopia, is uncommon and raises concern for new or recurrent fistula formation. METHODS: We report 2 patients with traumatic CCFs, where cranial nerve paresis resolved after endovascular CCF treatment only to reappear years later. RESULTS: No evidence of recurrent or new fistula formation was found. Both were treated successfully with strabismus surgery. CONCLUSIONS: Although the cause of delayed onset diplopia after successful treatment is still unknown, theories include late compression of cranial nerves within the cavernous sinus due to coil mass that can cause chronic ischemia, delayed inflammation due to a thrombophilic nidus created by the coil mass, or injury to the cranial nerves that manifests later due to decompensated strabismus.

Third nerve decompression by anterior petroclinoid ligament opening after clipping of posterior communicating artery aneurysm-How I do it.

BACKGROUND: Posterior communicating artery aneurysms sometimes present with partial or complete oculomotor nerve palsy, due to direct oculomotor nerve compression, irritation by subarachnoid blood, or both. Superiority of surgical clipping over endovascular coiling in terms of postoperative outcome is still controversial. METHOD: Direct oculomotor nerve decompression by opening of the anterior petroclinoid ligament during aneurysm clipping is performed as a simple and feasible surgical maneuver which allows to improve the decompression effect obtained by aneurysm exclusion. CONCLUSION: Anterior petroclinoid ligament opening permits to achieve a better oculomotor nerve decompression. Its efficiency on the recovery of the deficit needs to be proved by larger series.

A frontal external ventricular drain causing a third cranial nerve palsy.

This 47-year-old gentleman presented with acute hydrocephalus secondary to a colloid cyst. Bilateral external ventricular drains (EVDs) were inserted. The patient developed a third nerve palsy during post-operative period - cranial imaging demonstrated the tip of an EVD in this vicinity. The palsy recovered completely on slight withdrawal of the EVD.

Magnetic resonance imaging of bilateral split lateral rectus transposition to the medial globe.

PURPOSE: Medial transposition of the split or intact lateral rectus (LR) muscle in oculomotor palsy improves extreme exotropia. We studied rectus pulley positions using high-resolution surface coil MRI before and after LR split with medial transposition surgery in a patient with bilateral oculomotor and trochlear nerve palsies. METHODS: This is a report of a 14-year-old girl with 90Δ exotropia due to bilateral oculomotor and trochlear nerve palsies following traumatic midbrain infarction at age 6 years. Surgery comprised longitudinal division of each LR into a superior and inferior, threading of both halves between the inferior rectus (IR) and inferior oblique inferiorly, and inferior to the superior oblique and the superior rectus superiorly, with suturing of each 10 mm posterior to the medial rectus (MR) insertion. RESULTS: Pre-operative MRI of the orbit and extraocular muscles (EOMs) with thin, 2-mm slices revealed bilateral atrophy of all EOMs supplied by the oculomotor and trochlear nerves. Post-operative MRI at 2 months demonstrated no significant changes in rectus EOM pulley positions compared with pre-operative values. CONCLUSIONS: The LR pulley does not change position even after split LR transposition to the MR insertion, confirming the profound constraint of the connective tissue pulley system on the LR path.

Oculomotor nerve palsy induced by internal carotid artery aneurysm: prognostic factors for recovery.

BACKGROUND: Aneurysms at the posterior face of the internal carotid artery can lead to oculomotor nerve palsy (ONP) with an uncertain prognosis of recovery post-treatment. The aim of this study was to define the prognostic factors for ONP recovery, with particular interest in treatment modality (surgery or endovascular techniques). METHOD: A literature review was performed to select the most pertinent prognostic factors. A retrospective study was then performed to determine whether these factors had significantly modified the prognosis of ONP recovery in our series of patients. RESULTS: In the literature, factors linked to poorer outcome were age, vascular risk factors, initial ONP severity and delay before treatment; better recovery was associated with surgical treatment. Between 2000 and 2013, 23 consecutive patients were treated in our department for ONP-inducing aneurysms: 14 by endovascular embolization and 9 by surgical clipping and aneurysm puncture. Mean follow-up was 48.8 months. After treatment, overall recovery occurred in 87% of cases, always within 6 months. Apart from treatment modality, no selected prognostic factor significantly modified the quality or timing of ONP recovery. In the endovascular group, four patients recovered completely, seven partially and three did not recover. In the surgical group, seven patients recovered completely and two partially. Surgery was significantly associated with a more complete and earlier ONP recovery (p < 0.05). CONCLUSIONS: Surgery was associated with a more complete and earlier ONP recovery as compared to endovascular treatment, confirming the results of previous studies. However, conclusions must be confirmed by a prospective randomized study.

[Effects of Endovascular Treatment on Cranial Nerve Palsy due to Unruptured Intracranial Aneurysms].

This study aimed to assess the effects of endovascular treatment on cranial nerve palsy due to unruptured intracranial aneurysms. Endovascular coiling was performed in 203 patients with intracranial aneurysms between April 2002 and March 2012 in our hospital. Of these patients, 8(3.9%)presented with cranial nerve palsy due to unruptured intracranial aneurysms. Cranial nerve palsy involved the oculomotor nerve in 8 patients and the optic nerve in 2 patients. Two patients had both optic nerve and oculomotor nerve dysfunction. Patients with incomplete oculomotor nerve palsy at admission were more likely to have full recovery after coiling. Optic nerve dysfunction did not improve after coiling. Incomplete oculomotor nerve palsy, early treatment(≤15 days), and small aneurysms(≤10 mm)were likely to be associated with complete recovery after coiling. This study indicates that endovascular coiling may resolve cranial nerve palsy due to unruptured intracranial aneurysms in patients who have incomplete oculomotor nerve palsy due to small aneurysms and are treated as early as possible after symptom onset.

Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series.

BACKGROUND: Oculomotor nerve palsy (ONP) is a common clinical manifestation of ruptured or unruptured posterior communicating artery (PcomA) aneurysms. Although microsurgical clip ligation has been proven a safe and durable treatment, endovascular management is emerging as an increasingly popular alternative. The aim of our study is to compare the recovery rate from ONP and assess the safety and long-term durability of both techniques. METHODS: We have reviewed the retrospective data concerning twenty-two patients treated at our institution between 2004 and 2012 for PcomA aneurysms with ONP. Seven patients were operated on via a standard pterional approach, and fourteen were treated by endovascular occlusion with coils. One patient was managed conservatively. Pre-treatment and post-treatment severity of ONP was recorded, as well as the duration of symptoms before admission and treatment-related complications. RESULTS: All seven patients who underwent surgery improved, with six total recoveries and one partial recovery. Among the fourteen patients treated by embolization, thirteen initially recovered, but long-term follow-up revealed three cases of exacerbation of ONP after refilling of the aneurysms. Two of them were clipped, and one embolized. Also, one partially resolved patient underwent a second embolization. No severe complications occurred in either group. CONCLUSIONS: Despite the small number of patients, our study suggests that both surgical clipping and embolization are safe and effective methods in regards to functional recovery (complete ONP recovery in about 85 % of the cases). However, coiling may lead to delayed recurrence of third cranial nerve (CN) palsy at long-term follow-up, requiring additional treatment.

Recovery of oculomotor nerve palsy secondary to posterior communicating artery aneurysms.

BACKGROUND: Recent studies suggest more favourable recovery of oculomotor nerve palsy (ONP) caused by posterior communicating artery (PComA) aneurysms with microsurgical clipping compared to endovascular coiling. We describe a consecutive series of patients with ONP from PComA aneurysms treated by microsurgical clipping or endovascular coiling. METHODS: We retrospectively reviewed medical records of all patients from 2005 to 2009 with complete or partial ONP from PComA aneurysms. RESULTS: Twenty patients were identified, three with unruptured aneurysms. Two patients with ruptured aneurysms were unfit for treatment and therefore excluded. Of the 18 patients included (15 female), 9 underwent microsurgical clipping and 9 received endovascular coiling. Patients treated by surgical clipping were significantly younger compared to those treated by endovascular coiling (mean 52.3 vs. 67.9 years; p = 0.039). Five patients had incomplete ONP (3 clipped, 2 coiled) and thirteen had complete ONP. At 6 months, six of nine patients treated with clipping and five of nine patients treated with coiling had complete resolution of their ONP (p = 1.0); the remainder had partial improvement. There was no significant difference in duration of pre-treatment ONP, age, sex or status of aneurysm (ruptured or unruptured) between patients in the two groups or between those with full or partial recovery. However, all 5 patients with incomplete ONP at presentation recovered fully, compared with 6 of 13 patients who presented with complete ONP. CONCLUSIONS: We found no significant difference between clipping and coiling in the recovery of ONP due to PComA aneurysms. Patient who present with incomplete ONP are more likely to have a full recovery of ONP following either treatment modality than those who present with complete ONP.

Inferior oblique muscle anteriorization in congenital superior oblique palsy.

BACKGROUND: Inferior oblique muscle overaction of variable amounts is usually present with congenital superior oblique palsy. Inferior oblique muscle anteriorization has been described as a suitable surgical procedure in this entity. The aim of this study was to investigate the effect of inferior oblique muscle anteriorization in patients with congenital superior oblique palsy on vertical, torsional and horizontal alignment. PATIENTS AND METHODS: The study was designed as an institutional retrospective cohort study. 45 patients with congenital superior oblique palsy (15 female, 30 male; mean age 36 years ± 19.2 SD, ranging from 6 to 75 years) underwent inferior oblique muscle anteriorization between 2000 and 2010. Preoperative amounts of vertical, torsional and horizontal deviation (using Harms tangent screen), measurements of Bielschowsky head tilt phenomenon as well as stereopsis (Lang test) were compared with findings three months and one year postoperatively. RESULTS: Preoperative vertical deviation in primary position measured 10.1° (mean; range 0-19). Three months postoperatively vertical deviation was significantly reduced (p<0.001) to 4° (mean; range 0-20). After one year vertical deviation measured 3.5° (mean; range 0-15). The values three months postoperatively did not significantly differ from those one year postoperatively (p=0.46). CONCLUSIONS: Inferior oblique muscle anteriorization leads to a significant and sustained improvement of ocular alignment in patients with congenital superior oblique palsy of various degrees of severity. Thus the procedure is recommendable as a first line treatment in this clinical situation.