Implementation of a Magnetic Resonance Imaging scanner dedicated to emergencies in cases of binocular diplopia: Impact on patient management.

RATIONALE AND OBJECTIVES: Evaluate the implementation of an MRI scanner dedicated to emergencies on the management of patients admitted in the emergency department (ED) for binocular diplopia (BD). MATERIAL AND METHODS: This was a prospective non-interventional single-center study from February 2018 to February 2020. A total of 110 patients were included: 52 patients during the first stage (29 women; 23 men; mean age 65.2 years); 58 during the second stage (29 women; 29 men; mean age 51.4 years). Patients underwent an enhanced-CT examination in the first stage and an MRI examination in the second stage. Criteria used to evaluate the new management of patients were: proportion of patients with an imaging diagnosis explaining BD, turnaround time (TT), ED length of stay (EDLOS), hospital admission rate, hospital length of stay (HLOS), number of MRI examinations requested as a second procedure for the same indication and radiation doses. Descriptive statistics were used to present results with Student's test for quantitative variables and chi-square test for qualitative variables. RESULTS: Respectively 1 (1.92%) and 17 (29.31%) patients had definitive diagnosis in stages 1 and 2, with a significant difference in examination modalities (p=0.0001). The TT, EDLOS, hospital admission rate, and HLOS were not significantly different between the two stages. Radiation dose was significantly different between the two groups (p<0.05). CONCLUSION: Implementation of an MRI scanner dedicated to emergencies can improve the etiological diagnostic performance of binocular diplopia and reduce patient's exposure to ionizing radiation without increasing the average turnaround time or emergency department length of stay.

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.

MRI dedicated to the emergency department for diplopia or dizziness: a cost-effectiveness analysis.

OBJECTIVES: The purpose of this study was to compare the costs and organizational benefits of diagnostic workup without and with MRI dedicated to the ED. METHODS: We conducted a prospective observational uncontrolled before-after study in one ED of a university hospital in France from July 1, 2018, and January 3, 2020. We included all consecutive patients presenting with dizziness or diplopia. The main outcomes were the clinical decision time of ED physicians and the total costs for each strategy. Outcomes were compared using propensity score with inverse probability weighting in the 2 arms and an incremental cost-effectiveness ratio (ICER) was calculated. RESULTS: Among the 199 patients during the "before" period (average age: 60.4 years ± 17.6): 112 men (57%), and 181 during the "after" period (average age, 54.8 years ± 18.5): 107 men (59%), the average costs were €2701 (95% CI 1918; 3704) and €2389 (95% CI: €1627; 3280) per patient, respectively. The average time to clinical decision was 9.8 h (95% CI: 8.9 10.7) in the group "before" and 7.7 h (95% CI: 7.1; 8.4) in the group "after" (ICER: €151 saved for a reduction of 1 h in clinical decision time). The probabilistic sensitivity analysis estimated a 71% chance that the MRI dedicated to ED was dominant (less costly and more effective). CONCLUSION: Easy access to MRI in the ED for posterior circulation stroke-like symptoms must be considered a relevant approach to help physicians for an appropriate and rapid diagnostic with reduction of costs. TRIAL REGISTRATION: NCT03660852 KEY POINTS: • A dedicated MRI in the ED for diplopia or dizziness may be considered an efficient strategy improving diagnostic performance, reducing physicians' decision time, and decreasing hospital costs. • This strategy supports clinical decision-making with early treatment and management of patients with posterior circulation-like symptoms in the ED. • There is 71% chance that the MRI dedicated to ED was dominant (less costly and more effective) compared with a strategy without dedicated MRI.

Magnetic Resonance Imaging in Diplopia: Neural Pathway, Imaging, and Clinical Correlation.

The role of magnetic resonance imaging (MRI) in diplopia is to diagnose various diseases that occur along the neural pathway governing eye movement. However, the lesions are frequently small and subtle and are therefore difficult to detect on MRI. This article presents representative cases of diseases that cause diplopia. The purpose of this article was to 1) describe the anatomy of the neural pathway governing eye movement, 2) recommend optimal MRI targets and protocols for the diagnosis of diseases causing diplopia, 3) correlate MRI findings with misalignment of the eyes (i.e., strabismus), and 4) help familiarize the reader with the imaging diagnosis of diplopia.

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.

Isolated abducens nerve palsy in a patient with asymptomatic SARS-CoV-2 infection.

The neuro-ophthalmological complications of SARS-CoV-2 infection are emerging but the spectrum of presentations and pathophysiological mechanism underpinning the association remains to be fully determined. We describe the case of a 44-year-old female who presented with a 12-hour history of diplopia preceded by a mild headache and found to have an isolated right abducens nerve palsy. Initial vital signs were normal but she developed a fever and nasopharyngeal swab confirmed SARS-CoV-2 infection by RT-PCR. All other investigations returned normal including blood tests, chest X-ray, MRI brain and cerebrospinal fluid analysis. She remained systemically well, and there was complete resolution of the abducens palsy and diplopia at two week follow up. In the absence of an alternative underlying cause or risk factors identified, the aetiology was presumed to be microvascular and potentially related to the viral infection. We add to the evolving literature of neuro-ophthalmological associations of SARS-CoV-2, discuss possible causal mechanisms and suggest considering asymptomatic SARS-CoV-2 infection in cases of isolated abducens palsy without clear risk factors.

Acute-onset binocular diplopia in neurological unit: Aetiological factors and diagnostic assessment.

OBJECTIVES: To investigate the aetiology of acute-onset binocular diplopia (AOBD) in neurological units and identify the key diagnostic procedures in this setting. MATERIALS AND METHODS: Clinico-demographic data from patients hospitalized for AOBD from 2008 to 2019 were retrospectively reviewed. AOBD due to an underlying neurological disorder known to cause diplopia was addressed as secondary diplopia. Ophthalmoparesis plus was defined when subtle neurological signs/symptoms other than ophthalmoparesis were detected during neurological examination. RESULTS: A total of 171 patients (mean age 57.6 years) were included in the study. A total of 89 subjects (52%) had an oculomotor disturbance consistent with sixth nerve palsy, and 42 (24.6%) showed multiple oculomotor nerve involvement. The most common cause of AOBD was presumed to be microvascular in 56 patients (32.7%), while a secondary aetiology was identified in 102 (59.6%). Ophthalmoparesis plus and multiple oculomotor nerve involvement significantly predicted a secondary aetiology in multivariable logistic regression analysis. Brain CT was never diagnostic in isolated ophthalmoparesis. A combination of neuroimaging examinations established AOBD diagnosis in 54.9% of subjects, whereas rachicentesis and neurophysiological examinations were found to be performant in the remaining cases. CONCLUSIONS: AOBD may herald insidious neurological disease, and an extensive diagnostic workup is often needed to establish a diagnosis. Neurological examination was pivotal in identifying patients at higher risk of secondary aetiology. Even in cases of apparently benign presentation, a serious underlying disease cannot be excluded. Brain MRI was found to perform well in all clinical scenarios, and it should be always considered when managing AOBD.

Functional Anatomy of Muscle Mechanisms: Compensating Vertical Heterophoria.

PURPOSE: Magnetic resonance imaging (MRI) of extraocular muscle function was used to evaluate the role of newly recognized mechanisms underlying compensation of large heterophoria by vertical fusional vergence (VFV). DESIGN: Prospective case series. METHODS: At one academic center, 8 adults with large hyperphoria and supernormal VFV underwent MRI during monocular and binocular fixation of a centered, near target. Contractility of the rectus and superior oblique (SO) extraocular muscles in hypertropic and hypotropic eyes was determined from changes in posterior partial volume (PPV). RESULTS: Five of 8 patients could sustain binocular fusion in the scanner. In those patients, VFV corrected approximately 5-degree misalignment, approximately 5-fold greater than normal VFV. Vertical strabismus was compensated mainly by significant contractility of the lateral more than the medial compartment of the inferior rectus (IR) in both eyes (P < .005). The superior rectus (SR) and inferior oblique muscles had no significant contractile contribution, although the hypotropic SO relaxed significantly. The IR lateral compartment and SR medial compartment significantly co-relaxed when binocular fusion was attained from monocular target fixation (P < .01). CONCLUSIONS: Although VFV protects patients from small muscle imbalances over the lifespan, even enhanced VFV may be inadequate to avert diplopia. Compensation of hyperphoria by VFV is accomplished mainly by IR muscle relaxation in the hypotropic eye, principally in its selectively innervated lateral compartment, whereas the SO contributes little. Fusion involves compartmentally selective co-relaxation in hypotropic eye vertical rectus muscles. Taken together, these overall findings suggest a physiologic basis to prefer therapeutic surgical weakening of the medial IR in the hypotropic eye.

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.

Trochlear nerve palsy associated with Moyamoya disease.

A 48-year-old woman with intracranial hemorrhage at the right hemisphere and the right midbrain was diagnosed as Moyamoya disease (MMD). While restoring consciousness, she complained of diplopia. The left hypertropia with a compensatory right head tilt was noted. The follow up brain image showed the evidence of past hemorrhage at the level of the right inferior colliculus. In this case, the hemorrhage directly damaged the right trochlear nucleus or intra-axial trochlear nerve before decussation and caused left (contralateral) hypertropia. To our knowledge, no report has been described of the trochlear nerve palsy in hemorrhagic Moyamoya disease. Here, we present a case of the patient with trochlear nerve palsy after hemorrhagic MMD and summarize the characteristics of trochlear nerve palsy according to its lesion sites.

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.