Tapia Plus: un nuevo síndrome o una variante / Tapia syndrome plus: A new entity or a variant of Tapia syndrome?

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Physiotherapy in Postinfection Injury to Cranial Nerves III, IV, and VI: A Case Study.

The patient with bacterial infection sequelae in the form of damage to cranial nerves III, IV, and VI was followed up. He had exhibited clinical and radiographic signs of paranasal sinusitis. Before his physiotherapy, the patient received standard treatment with natural and synthetic antibiotics and steroids. After acute signs of infection resolved without any functional improvement, the patient was referred to a rehabilitation unit to undergo neuromuscular re-education of the paralyzed extraocular muscles. Periorbital hydrocortisone iontophoresis and visuomotor exercises with intense ideomotor stimulation led to complete and rapid resolution of extraocular muscle paralysis and diplopia. Physiotherapy can be an effective treatment of choice after failed pharmacological treatment in patients with damage to cranial nerves III and VI. It has many theoretical advantages, including noninvasiveness and avoidance of first-pass metabolism of drugs administered systemically.

Parálisis unilateral aislada del nervio oculomotor común posterior a trauma craneoencefálico leve / Isolate unilateral oculomotor palsy after mild traumatic brain injury

La parálisis aislada del nervio oculomotor común (NOC) es una presentación clínica infrecuente del traumatismo craneoencefálico (TCE) leve. Escasas son las descripciones de casos en los que se ha podido demostrar el daño aislado del NOC por avulsión de las raíces con lesión axonal traumática y microhemorragia intraneural. Presentamos el caso de una paciente de 23 años que posterior a TCE leve inició con ptosis palpebral derecha, diplopía binocular y fotofobia. Al examen clínico se apreció una oftalmoparesia completa del III par craneal derecho, sin otras alteraciones. Los exámenes de neuroimagen no demostraron daño estructural compresivo sobre el NOC afectado. Se realizó resonancia magnética (RM) con ECO de gradiente y T1 contrastado. Demostrándose signos de hemorragia intraneural del NOC derecho, además de lesión axonal traumática desde su origen en el pedúnculo cerebral derecho hasta alcanzar la fisura orbitaria. Protocolos específicos de RM contribuyen a evidenciar lesiones aisladas del NOC

Isolated traumatic oculomotor nerve (ON) palsy is an uncommon clinical presentation of mild traumatic brain injury (TBI). There are very few cases in which it has been possible to demonstrate the isolated damage of the ON by avulsion of the roots, accompanied with traumatic axonal injury and intraneural microhemorrhage. We present a 23-year-old female who, after mild TBI, began to experience right ptosis, binocular diplopia, and photophobia. Clinical examination showed a complete ophthalmoparesis of the right ON, without other neurological deficits. Neuroimaging studies demonstrated no structural compressive damage of the right ON. Magnetic resonance imaging (MRI) with Gradient-echo and T1 weighted post-gadolinium was made, demonstrating signs of intraneural hemorrhage of the right ON, in addition to traumatic axonal injury extending from the right cerebral peduncle to the orbital fissure. Specific MRI protocols contribute as evidence of an isolated lesion to the ON

Parálisis nuclear del III par craneal en el contexto de un traumatismo craneoencefálico / Nuclear paralysis of the oculomotor nerve within the context of traumatic brain injury

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Incarceration of the inferior oblique muscle branch of the oculomotor nerve in patients with orbital floor trapdoor fracture.

PURPOSE: To examine the clinical characteristics of patients with concomitant incarceration of the inferior oblique muscle branch of the oculomotor nerve who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. METHODS: Fifty-nine patients were retrospectively reviewed. Concomitant inferior oblique muscle branch incarceration was diagnosed by inferior oblique muscle underaction on the Hess chart and a missing inferior oblique muscle branch on computed tomographic images on baseline examination. RESULTS: Eleven patients (18.6%) were diagnosed with concomitant branch incarceration. The patients with branch incarceration were all under 19 years of age, and were younger than those without branch incarceration (P = 0.026). There were no significant differences between the groups in terms of cause of injury, presence of concomitant medial wall fracture, hypoesthesia of the cheek region, or ocular and periocular complications (P > 0.050). All patients with branch incarceration underwent surgical reduction, whereas 16 of 48 patients without branch incarceration were observed without surgery (P = 0.021). Although preoperative binocular single vision field was smaller in patients with branch incarceration (P = 0.026), it improved after surgery, comparable to that of patients without branch incarceration (P = 0.079). CONCLUSIONS: Concomitant incarceration of inferior oblique muscle branch of the oculomotor nerve occurred in 18.6% of patients who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. Patients with branch incarceration were all under 19 years of age. Branch incarceration resulted in a smaller binocular single vision field, which considerably improved after surgical reduction.

Diffusion Tensor Imaging Tractography Detecting Isolated Oculomotor Nerve Damage After Traumatic Brain Injury.

A 24-year-old woman was hit by a bus and suffered an isolated complete oculomotor nerve palsy. Computed tomography scan did not show a skull base fracture. T2*-weighted magnetic resonance imaging revealed petechial cerebral hemorrhages sparing the brainstem. T2 constructive interference in steady state suggested a partial sectioning of the left oculomotor nerve just before entering the superior orbital fissure. Diffusion tensor imaging fiber tractography confirmed a sharp arrest of the left oculomotor nerve. This recent imaging technique could be of interest to assess white fiber damage and help make a diagnosis or prognosis.

Clinical characteristics and prognosis factors analysis for post-operative ptosis of sphenocavernous meningiomas: a single institution study.

OBJECTIVE: Complete and safe resection of sphenocavernous (SC) meningiomas is difficult and also a great challenge for neurosurgeons. The goal of our study was to report the surgical results and complications for these patients treated at our institution as well as trying to find the factors resulted in ptosis after the operation. MATERIALS AND METHODS: Forty-nine consecutive SC meningiomas cases that underwent surgery between April 1997 and December 2012 were reviewed. The clinical courses of all patients were recorded. Prognosis factors of post-operative ptosis were evaluated. RESULTS: There were 38 female and 11 male patients. Mean duration of symptoms was 20.9 months. Visual deficit (34.7%) and headache (22.4%) were the most common presenting symptoms. Mean maximum diameter of the tumors on MRI was 5.1 cm. Subtotal resection was achieved in 51.0% of patients. Follow-up data were available for 39 patients, with a mean follow-up of 73.7 months, and four patients died during follow-up period. Of the 35 living patients, 22 (62.9%) lived a normal life. Univariate analyses showed that factors associated with post-operative ptosis included female patient, with primary operation and the cavernous extension in Category 3 of Hirsch' grading, while multivariate regression analyses showed that only the cavernous extension in Category 3 of Hirsch' grading was independently associated with post-operative ptosis. CONCLUSIONS: Our experience suggests that the most common complication after the SC meningioma surgery is ocular cranial nerve dysfunction, and the only significance factor relative to post-operative ptosis is the level of extension to the cavernous.

Sinquinesis óculomotora: dos casos de pacientes excepcionales / Oculomotor synkinesis: two cases excepcional patients

Las sinquinesis son movimientos simultáneos o coordinados en secuencia de mivimientos de músculos suplidos por diferentes nervios o por ramas independientes del mismo nervio que ocurren luego de la recuperación de una lesión axonal periferica; son debidos a la dirección errónea ("misdirection") que toman algunos axones hacia otros músculos que no constituyen su objetivo o blanco; así, cuando el paciente intenta mover algunos músculos, ocurren contracciones involuntarias en otros, no esperadas anatómicamente. Es una suerte de recableado mal realizado y confuso. En las dos pacientes que constituyen nuestro informe, ocurrieron alteraciones óculomotoras excepcionales. En la primera de 60 años portadora de un aneurisma gigante del senocavernoso izquierdo, la sinquinesis nerviosa aberrante ocurrió entre los nervios craneales tercero y sexto. En la segunda de 22 años a quien se resecó un osteocondroma gigante de la fosa media derecha, desarrolló una parálisis total del tercer nerviocraneal con sinquinesis trigémino-oculomotora entre el músculo pterigoideo derecho y el elevador del párpado superior; así como también entre el tercero (recto inferior) y sexto nervios (recto externo) ipsolateral. Se revisa la literatura al respecto.

Synkinesis are simultaneous or coordinated sequential movements of muscles that are supplied by different nerves or have independent nerve branches. They occur after the recovery a peripheral axonal injury. They are due to axons taking a wrong direction ("misdirection") towards muscles that do not constitute their objetives or targets. Thus, when the patient attempts to move a muscle, other muscles show anatomically unexpected involuntary contractions. It is a sort of confusing rewiring. Our report is based on the exceptional oculomotor alterations that occurred in two patients. In the first patient, a 60 years-old female carrying a giant aneurysm of the left cavernous sinus, the aberrant nerve synkinesis ocurred between the third and sixth cranial nerves. In the second patient, a 22 year-old female to whom was resected a giant osteochondroma of the right middle fossa, developed a total paralysis of the third cranial nerve with trigeminal oculomotor synkinesis between the right pterygoid muscle and the elevator of the upper eyelid; as well as between the inferior rectus and ipsilateral external rectus. We review the literature on the subject.

Incomplete oculomotor nerve palsy in the subarachnoid space caused by traumatic brain injury.

A patient with traumatic brain injury showed incomplete oculomotor nerve palsy in the subarachnoid space. A 12-year-old girl was hospitalized after a head injury. Neuro-ophthalmic examination showed that the left eye had a ptosis and pupillary involvement. An MRI indicated an intracranial hematoma at the basilar portion of the left temple. The ptosis and pupillary involvement improved after elimination of the hematoma. The presentation patterns are best explained by topographic organization of the third nerve fiber within the subarachnoid space. This case suggests that the topographic organization of the third nerve should be considered in diagnosis of oculomotor nerve palsy.

Aberrant regeneration of the third cranial nerve.

BACKGROUND: Aberrant regeneration of the third cranial nerve is most commonly due to its damage by trauma. CASE: A ten-month old child presented with the history of a fall from a four-storey building. She developed traumatic third nerve palsy and eventually the clinical features of aberrant regeneration of the third cranial nerve. The adduction of the eye improved over time. She was advised for patching for the strabismic amblyopia as well. CONCLUSION: Traumatic third nerve palsy may result in aberrant regeneration of the third cranial nerve. In younger patients, motility of the eye in different gazes may improve over time.