Superior divisional third nerve palsy due to breast cancer metastasis to the orbital apex.

PURPOSE: To report a case of breast cancer with metastasis to the orbital apex with manifestation of superior divisional third nerve palsy. CASE DESCRIPTION: A 40-year-old female, a known case of breast cancer diagnosed 3 years ago, referred to our neuro-ophthalmology clinic with chief complaint of ptosis and diplopia. In ophthalmic examination, visual acuities of both eyes were 20/20 and there was no significant finding in the anterior and posterior segment ophthalmic examination. There was left eye ptosis with MRD1 of 2 mm. In ocular movement examination, there was limitation of motion in supraduction (-2 to -3) of the left eye. Orbital MRI with contrast was requested for the patient which demonstrated a lesion in the orbital apex of the left eye. At the end, the patient was diagnosed as having superior divisional third nerve palsy. Orbital radiotherapy was recommended for the patient. CONCLUSION: In a patient with breast cancer who presents with diplopia, metastasis to the orbital apex with manifestation of divisional third nerve palsy should be kept in mind, and appropriate orbital imaging should be considered.

A Rare Intracranial Collision Tumor of Meningioma and Metastatic Uterine Adenocarcinoma: Case Report and Literature Review.

BACKGROUND: A collision tumor is a rare entity consisting of 2 histologically distinct tumor types (benign or malignant) in the same anatomic location. This can occur from a tumor-to-tumor metastasis or as a result of 2 adjacent intracranial tumors colliding and growing together. To our knowledge, this is the first reported case of collision tumor with confirmed meningioma and uterine adenocarcinoma. Multiple mechanisms have been proposed for the facilitative growth of collision tumors, including local epigenetic signaling. Clinically, it is important to consider collision tumors in the differential diagnosis of a rapidly growing intracranial lesion in the setting of systemic cancer to provide optimal surgical and postoperative management. CASE DESCRIPTION: A 78-year-old, right-handed woman with a known 10-year history of stable meningioma presented for evaluation of a right sphenoid wing lesion. She had recently completed treatment of uterine papillary serous carcinoma with no evidence of disease on follow-up imaging. On presentation, there was significant progression of the meningioma resulting in brain compression and right third nerve palsy. The patient underwent urgent resection of the lesion. Pathology demonstrated a collision tumor with a combination of metastatic uterine papillary serous carcinoma and meningioma. CONCLUSIONS: It is important to consider a collision tumor when a patient with a benign intracranial lesion presents with rapid progression, even in the context of a systemic cancer that rarely metastasizes to the brain. Appropriate histopathologic assessment is crucial in these cases and can have a significant impact on treatment plan and prognosis.

Disseminated lymphoblastic lymphoma revealed by an isolated third cranial nerve palsy.

Dysfunction of the third cranial nerve can be provoked by a number of different conditions. An isolated cranial neuropathy as a first clinical sign of a non-Hodgkin lymphoma is very infrequent. We represent here an atypical case of lymphoblastic lymphoma revealed by an isolated third cranial nerve palsy. The patient was managed by alternating cycles of cyclophosphamide, vincristine, and prednisone. She made a full recovery with a complete resolution of the symptomatology.

Nasopharyngeal B-cell lymphoma with pan-hypopituitarism and oculomotor nerve palsy: a case report and review of the literature.

BACKGROUND: Primary nasopharyngeal lymphoma (NPL) is a very rare tumor of Waldeyer ring (WR) lymphoid tissue. It is challenging to differentiate lymphoma infiltration of pituitary from a pituitary adenoma, meningioma infiltration, and other sellar lesions to plan a suitable treatment strategy. We presented for the first time a unique case of NPL with an unusual presentation of oculomotor nerve palsy associated with pan-pituitary involvement in a diabetic patient. CASE PRESENTATION: A 64-year old diabetic woman with no previous history of malignancy presented with intermittent diplopia for about the last nine months. Severe headache, left eye ptosis and hypoglycemic episodes were added to her symptoms after a while. Further complaints include generalized weakness, loss of appetite, generalized musculoskeletal pain, and 6-7 kg weight loss within six months. Her family history was unremarkable. Physical examinations of eyes indicated left eye 3rd, 4th, and 6th nerve palsy. But, she was not anisocoric, and the pupillary reflexes were normal on both eyes. No lymphadenopathy, organomegaly and other abnormalities were found. Magnetic resonance imaging (MRI) showed a heterogeneous enhancement in the seller and suprasellar regions, enlargement of the stalk, parasellar dural enhancement and thickening of the sphenoid sinus without bone erosion. Also, both cavernous sinuses were infiltrated and both internal carotid arteries were encased by the neoplastic lesion. It suggested an infiltrative neoplastic lesion which compressed the cranial nerves. Pituitary hormone levels assessment indicated a pan-hypopituitarism. Following nasopharyngeal mucosal biopsy, the immunohistochemistry (IHC) findings revealed a low-grade non-Hodgkin's B-cell lymphoma. Systemic workup, including cerebrospinal fluid (CSF) studies, bone marrow aspiration, chest and abdominopelvic high-resolution computed tomography (HRCT) indicated no other involvement by the lymphoma. After chemotherapy courses, central adrenal insufficiency, partial central diabetes incipidious (CDI) and central hypothyroidism have been resolved. To our best knowledge, we found 17 cases of NPL with cranial nerve palsy, 1 case of NPL with pan-hypopituitarism and no NPL case with both cranial nerve palsy and pituitary dysfunction. CONCLUSIONS: The incidence of cranial neuropathy in patients with diabetes should not merely be attributed to diabetic neuropathy without further evaluation.

Oculomotor Neurofibroma: A Different Histology Implying an Unsatisfying Clinical Outcome.

BACKGROUND: Tumors arising from oculomotor nerve are rare, with few cases reported in the literature. Generally, whereas schwannomas are well encapsulated tumors, neurofibromas tend to invade the entire nerve fibers. These differences influence surgical resection and neurological clinical outcome, with neurofibroma often requiring the sacrifice of the nerve. Accordingly, an incorrect preoperative diagnosis can lead to incomplete patient counseling before surgery. CASE DESCRIPTION: We report 2 cases: a patient with oculomotor schwannoma and a patient with oculomotor neurofibroma. After tumor resection, the patient with a diagnosis of schwannoma recovered with 3rd nerve palsy, while patient with the neurofibroma developed a complete oculomotor nerve deficit. For each patient, surgical strategy and neurological outcome are elucidated in relation with differences in preoperative magnetic resonance imaging and histology. CONCLUSIONS: To the best of our knowledge, this is the first report of an oculomotor neurofibroma. When an oculomotor nerve tumor is suspected, a careful preoperative evaluation of magnetic resonance imaging guides in distinguishing the different histology, in selecting the treatment strategy, and in correctly informing the patient on expected postoperative neurologic outcome.

Isolated cranial neuritis of the oculomotor nerve: Expanding the MOG phenotype?

Autoantibody against myelin oligodendrocyte glycoprotein (MOG) has been reported in a range of demyelinating neurological entities. Recent studies demonstrate a wider spectrum of MOG-IgG-associated disorders with the discovery of MOG-IgG-positive brainstem encephalitis, cortical encephalitis, and cranial nerve involvement with concurrent central nervous system involvement. We present a MOG-IgG-positive pediatric patient diagnosed with isolated oculomotor neuritis without concurrent central nervous system neuroimaging lesions, in the absence of a demyelinating event. Brain MRI shows swelling and gadolinium enhancement of the left oculomotor nerve at the cisternal segment. This is the first report to demonstrate MOG-IgG seropositivity in isolated cranial nerve lesions. This case may expand the clinical phenotype of MOG-IgG-associated diseases, and clinicians should not hesitate to test for MOG-IgG in cases with neuroimaging features of cranial neuritis alone.

Vascular anomaly of the posterior circulation associated with intracranial lipoma-like lesion in the cerebral peduncle manifesting as oculomotor nerve palsy.

Intracranial lipomas are rare and often located in the midline of the brain. Intracranial lipomas are often associated with malformations of the brain such as dysgenesis of the corpus callosum, but rarely with vascular malformations. A man presented with left-sided facial pain at the age of 31. He developed left oculomotor nerve palsy at the age of 38 years and was referred to our hospital at the age of 48. Radiological findings revealed vascular anomalies of the left posterior cerebral and superior cerebellar arteries with intracranial lipoma-like lesion in the cerebral peduncle. Surgical treatment was complicated by the lesion location, so we administered conservative therapy. Despite treatment with corticosteroids, his symptoms have not improved. This unique case documents the presentation of vascular anomalies of the left posterior cerebral and superior cerebellar arteries associated with lipoma in the cerebral peduncle.

Quantitative analysis of pupillometry in isolated third nerve palsy.

OBJECTIVES: To objectively assess pupillary involvement according to various etiologies of acquired isolated third nerve palsy using automated pupillometry, and evaluate the efficacy of digital pupillometry in discriminating compressive lesions from microvascular ischemic third nerve palsy. DESIGN: Retrospective, observational case series. METHODS: A total of 171 subjects were included in this study, consisting of 60 subjects with presumed microvascular ischemic third nerve palsy, 51 with non-ischemic third nerve palsy, and 60 controls whose pupillary light responses were measured using a dynamic automated pupillometer. Subjects with non-ischemic third nerve palsy were divided into subgroups according to their etiology; inflammatory and compressive groups including tumor and aneurysm. Pupillometry parameters including minimum and maximum pupil diameters, constriction latency and ratio, maximum and average constriction velocities and dilation velocity were noted. The diagnostic ability of pupillometry parameters for discriminating compressive vs microvascular ischemic third nerve palsy was evaluated. The inter-eye difference of the involved eye and the uninvolved fellow eye was calculated to adjust for individual variability. RESULTS: Among all parameters, reduced pupillary constriction ratio was the most specific parameter for detecting non-ischemic third nerve palsy, as a large inter-eye difference beyond the normative range of controls was found in 0% of ischemic, 20% of inflammatory and 60% of compressive third nerve palsy. With the diagnostic criteria using inter-eye differences of 1) minimum pupil diameter > 0.45 mm, or 2) pupillary constriction ratio < -7.5% compared to the fellow eye, the sensitivity and specificity for diagnosing compressive third nerve palsy were 95% and 88%, respectively. In the compressive group, positive correlations were found between the degree of external ophthalmoplegia and constriction ratio (r = 0.615, p<0.001), average constriction velocity (r = 0.591, p = 0.001) and maximum constriction velocity (r = 0.582, p = 0.001). CONCLUSIONS: Abnormal pupillary constriction ratio was highly specific for detecting compressive third nerve palsy, although the sensitivity was not high. Digital pupillometry demonstrated relatively good performance for discriminating compressive lesions from microvascular ischemic third nerve palsy.

Arteritis de células gigantes en el sistema vertebrobasilar, isquemias cerebelo-occipitales y parálisis III par: caso clínico / Giant cell arteritis of the vertebrobasilar system, posterior ischemia and palsy of the third nerve: report of one case

Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan.

Isolated Oculomotor and Abducens Nerve Palsies as Initial Presentation of Cavernous Sinus Tuberculoma: Case Report and Literature Review.

BACKGROUND: Central nervous system tuberculoma is the most severe manifestation of extrapulmonary tuberculosis with high mortality. Cavernous sinus tuberculoma (CST) is a very rare central nervous system tuberculoma with few cases reported in the literature. CASE DESCRIPTION: A 57-year-old woman was admitted to our clinic with acute diplopia and headache limited to the right side. There was no specific medical history except for migraine, depression, and anxiety, all of which were controlled by oral medications. Physical examination revealed ptosis and mydriasis in the right eye, which indicated right third and sixth cranial nerve palsies. Pituitary magnetic resonance imaging showed a right parasellar lesion at the cavernous sinus wall and ophthalmic nerve. Laboratory examinations and brain computed tomography scan showed negative findings. Initial differential diagnosis included meningioma, sarcoidosis, tuberculoma, and lymphoma. However, results of further studies, including blood and cerebrospinal fluid cultures and Mycobacterium tuberculosis DNA assay, were negative. Biopsy of the cerebral lesion was performed through the subfrontal approach, and histopathologic study confirmed CST. She was treated with a standard antituberculous regimen. After 12 months of follow-up, no cerebral or clinical findings were seen. CONCLUSIONS: CST is a rare presentation of M. tuberculosis, and the diagnosis is a difficult challenge. However, accurate diagnosis and timely treatment of CST can result in complete cure.

[Giant cell arteritis of the vertebrobasilar system, posterior ischemia and palsy of the third nerve. Report of one case]. / Arteritis de células gigantes en el sistema vertebrobasilar, isquemias cerebelo-occipitales y parálisis III par. Caso clínico.

Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan.

[Diplopia: An important symptom in internal medicine!] / Diplopie : un symptôme important en médecine interne !

Diplopia is defined as "double vision" when looking at a single object. Monocular diplopia is related to an ocular disorder and must be differentiated from binocular diplopia which is secondary to ocular misalignment. The examination of the patient with binocular diplopia is often challenging for non-specialists. However, a careful and systematic clinical examination followed by targeted ancillary testing allows the clinician to localize the lesion along the oculomotor pathways. The lesion may involve the brainstem, the ocular motor nerves III, IV or VI, the neuromuscular junction, the extraocular ocular muscles, or the orbit. Causes of binocular diplopia are numerous and often include disorders typically managed by internal medicine such as inflammatory, infectious, neoplastic, endocrine, and metabolic disorders. In addition to treating the underlying disease, it is important not to leave diplopia uncorrected. Temporary occlusion of one eye by applying tape on one lens or patching one eye relieves the diplopia until more specific treatments are offered should the diplopia not fully resolve.

Magnetic resonance imaging of the functional anatomy of the superior oblique muscle in patients with primary superior oblique overaction.

PurposeTo quantitatively determine the size and contractility of the superior oblique (SO) muscle in primary SO overaction (PSOOA).Patients and methodsA prospective, observational study was conducted on 12 patients with PSOOA, and 10 healthy, orthotropic subjects. Sets of contiguous, 2 mm slice thickness, quasi-coronal magnetic resonance imaging were obtained during different gazes, giving pixel resolution of 0.391 mm. Cross-sectional areas of the SO muscles were determined in primary position, supraduction, and infraduction to evaluate size and contractility. The cross-sectional areas of SO muscle were compared with those of controls in the primary position to detect hypertrophy or atrophy and changes in contractility could be detected during the vertical gaze. All statistical calculations were performed using PROC MIXED (SAS 9.4).ResultsThere was no difference between the ipsilesional (affected eye), contralesional (unaffected eye), and normal SO muscle cross-sections: 0.176±0.018 cm2, 0.175±0.005 cm2, and 0.173±0.015 cm2, respectively (P=0.82). The maximum contractility of SO muscle on the ipsilesional (affected) side was 0.097±0.024 cm2, and was different than on the contralesional (unaffected) side: 0.067±0.015 cm2 and in control subjects: 0.063±0.018 cm2 (P=0.0002).ConclusionsIn PSOOA, the ipsilesional SO is more contractile than the contralesional SO muscle and different than in controls, with no difference in SO muscle size in primary position, which suggests that excessive innervation rather than muscle hypertrophy underlies PSOOA.

Oculomotor Nerve Palsy Complicates Third Ventricle Colloid Cyst Endoscopic Removal: Case Report.

BACKGROUND: A colloid cyst is a rare benign tumor. If indicated, surgical treatment can be realized using a microsurgical technique or an endoscopic technique. We report an uncommon complication of a third ventricle colloid cyst endoscopic removal. CASE DESCRIPTION: The cyst was incidentally discovered on computed tomography scan workup for mild head trauma in a 20-year-old male. Minor headache and minor memory loss were noted on clinical examination. Magnetic resonance imaging workup revealed obstructive hydrocephaly of the lateral ventricles associated with left uncal herniation. Surgery was uneventful. However, left oculomotor palsy was noted postoperatively. Workup revealed oculomotor nerve injury and isolated left mammillary body ischemia, secondary to worsened uncal herniation. This worsening might be caused by acute left ventricle hydrocephaly ascribed to interventricular foramen obstruction during cyst removal. CONCLUSION: Therefore, in similar presentation, realizing septum fenestration before cyst removal should relieve the pressure in the lateral ventricles thus decreasing the risk of herniation.