Motor Nerve Palsies Research Articles

Curved Periacetabular Osteotomy for Treatment of Dysplastic Hip

The Bernese periacetabular osteotomy has a considerable rate of postoperative complications such as reflex sympathetic dystrophy, motor nerve palsy, heterotopic ossification, and delayed union of the ilium, which are assumed to be caused by extensive exposure or asphericity of the osteotomy surfaces. To address these issues, we developed the curved periacetabular osteotomy, a modification of the Bernese periacetabular osteotomy which limits dissection, prevents the outside of the ilium from being exposed, and produces osteotomy surfaces with the same curvature. Curved periacetabular osteotomies were done on 128 hips in 118 patients whose average age at the time of surgery was 35.2 years (range, 16-59 years). The average followup was 46 months (range, 24-99 months). The average center-edge angles were 4 degrees (range, -15 degrees -5 degrees ) preoperatively and 35 degrees (20 degrees -55 degrees ) postoperatively, and union of the iliac osteotomy was achieved in all hips. We experienced three asymptomatic pubic nonunions. Dysesthesias occurred in 27 patients along the lateral femoral cutaneous nerve and symptoms resolved in 23 patients within 1 year. The average Harris hip score improved from 72 to 93 points. There were no major complications such as sciatic nerve palsy, abductor dysfunction, or heterotopic ossification. Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Imaging of a fourth ventricle arachnoid cyst in a child

A little girl aged 2.5 years presented with left-sided facial weakness of acute onset and approximately 9 months duration (according to the mother). There was no history of a previous viral illness, ear discharge or trauma. The child’s behaviour was reported as normal and there was no impairment in developmental and motor skills. Her delivery had been normal and her birth weight was 2.1 kg. Neurological examination confirmed a left 7th cranial nerve lower motor nerve palsy, with no associated 6th nerve involvement or bulbar palsy. Fundoscopy was normal and there were no signs of raised intracranial pressure, nor were cerebellar signs elicited. Power and deep tendon reflexes in the limbs were normal. CT demonstrated a cystic mass of the fourth ventricle, and MRI was requested for further evaluation. MRI of the brain was performed before and after gadolinium DTPA contrast injection, in the sagittal

Radial nerve palsy associated with high-energy humeral shaft fractures

Purpose To determine whether the radial nerve should be explored when there is a complete sensory and motor deficit after a high-energy fracture of the humeral diaphysis. Methods Twenty-four patients aged 16 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. Eleven fractures were open—6 of these were part of a very complex upper-extremity injury (multiple ipsilateral fractures in 3 patients and near amputation in 3). All 11 patients with open fractures and 3 of 13 patients with closed injuries had radial nerve exploration. Results All 6 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. Five of 6 had primary repair of the radial nerve, and none recovered. All 8 intact explored nerves and 9 of 10 unexplored nerves recovered; the only nonrecovery occurred in a patient treated with closed intramedullary rod fixation who may have had iatrogenic nerve injury. The average time to initial signs of recovery was 7 weeks (range, 1–25 weeks). The average time to full recovery was 6 months (range, 1–21 months). Conclusions Transection of the radial nerve is usually associated with open fractures of the humerus that are part of a very complex upper-extremity injury. The results of primary nerve repair in this circumstance are poor, likely related to an extensive zone of injury and the need for nerve grafting. Intact nerves and nerve palsies that are part of a closed fracture nearly always recover, even after high-energy injuries. Because the first signs of nerve recovery and complete recovery of the nerve can be quite delayed, patience is merited before considering tendon transfers.

Brainstem diseases causing isolated ocular motor nerve palsies

There is a significant number of individual patients with ocular motor nerve palsies as the only clinical sign of MRI- and, less frequently, CT-documented small brainstem lesions with a predominance of infarctions and hemorrhages in the 3 rd and 4 th nerves and demyelinating lesions in the 6 th nerve. The 3 rd nerve is most commonly and the 6 th and 4 th nerves less frequently involved. An intra-axial basis for isolated ocular motor nerve palsies may be underestimated if based on MRI-documented lesions only, as electrophysiologic abnormalities indicating brainstem lesions may be independent of MRI-documented lesions.This paper reviews neuroimaging and electrophysiological data on brainstem diseases manifesting as isolated ocular motor nerve palsies. It supports the concept that small pontine and mesencephalic lesions are an underestimated cause of isolated ocular motor nerve palsies and the main cause of nontraumatic 3 rd and 6 th nerve palsies in the middle-aged and elderly population.

Seventh nerve palsies may be the only clinical sign of small pontine infarctions in diabetic and hypertensive patients.

Small brainstem infarctions are increasingly recognized as a cause of isolated ocular motor and vestibular nerve palsies in diabetic and/or hypertensive patients. This raises the question whether there are also isolated 7(th) nerve palsies due to pontine infarctions in patients with such risk factors for the development of cerebrovascular diseases. Over an 11-year-period, we retrospectively identified 10 diabetic and/or hypertensive patients with isolated 7(th) nerve palsies and electrophysiological abnormalities indicating pontine dysfunction. All patients had examinations of masseter and blink reflexes, brainstem auditory evoked potentials, direct current electro-oculography including bithermal caloric testing, and T1- and T2-weighted MRI (slice thickness: 4-7 mm). Electrophysiological abnormalities on the side of the 7(th) nerve palsy included delayed masseter reflex latencies (4 patients), slowed abduction saccades (4 patients), vestibular paresis (2 patients), and abnormal following eye movements (2 patients). Electrophysiological abnormalities were always improved or normalized at re-examination, which was always associated with clinical improvement. MRI revealed an ipsilateral pontine infarction in 2 patients. Another 2 had bilateral hyperintense intrapontine lesions, and one an ipsilateral cerebellar infarction. Simultaneous improvement or recovery of abnormal clinical and electrophysiological findings strongly indicated that both were caused by the same actual pontine lesions. A 7(th) nerve palsy may be the only clinical sign of a pontine infarction in diabetic and/or hypertensive patients. Such mechanism may be underestimated if based on MRI only.

Long-term prognosis in patients with vasculopathic sixth nerve palsy

PURPOSE: To better define the long-term prognosis in patients with a vasculopathic sixth nerve palsy (6NP), specifically addressing the degree of recovery and incidence of recurrent similar episodes.DESIGN: Observational case series.METHODS: Retrospective chart review.SETTING: An outpatient neuroophthalmic practice.STUDY POPULATION: Patients with one or more vascular risk factors and an acute, isolated 6NP that spontaneously recovered.OBSERVATION PROCEDURE: Information regarding resolution of the 6NP, subsequent vascular events and recurrent ocular motor nerve palsy was obtained from chart review of follow-up clinic visits, mailed questionnaires and telephone interviews. The duration of follow-up ranged from 2 to 13 years.MAIN OUTCOME MEASURES: Resolution of 6NP (complete or incomplete) and incidence of recurrent ocular motor nerve palsy.RESULTS: Fifty-nine patients were identified with a mean age of 65.3 years ± 11.6 (range 34–90 years). Fifty-one patients (86%) experienced complete resolution of their first episode of vasculopathic 6NP and eight patients (14%) had incomplete resolution. A subsequent episode of ocular motor mononeuropathy occurred in 18 of 59 (31%) patients. The number of recurrences ranged from one (in 14 patients) to four (in one patient). There was no association between any risk factor and recurrence of ocular motor nerve palsy. Similarly, incomplete resolution of the vasculopathic 6NP was not associated with any risk factor.CONCLUSIONS: Patients with a vasculopathic 6NP usually have complete resolution of their ophthalmoplegia, but nearly one third of patients in our study later experienced at least one episode of recurrent vasculopathic ocular motor nerve palsy.

Smooth pursuit eye movements in patients with ocular motor nerve palsies: A preliminary report

The trajectories, velocity, and co-ordination of smooth pursuit eye movements were investigated in 30 patients with ocular motor nerve palsies (including palsies of cranial nerves III, IV and VI). The recordings of horizontal and vertical eye movements were obtained by video-oculography under monocular viewing conditions. During the recordings, horizontal, vertical, and oblique target movements of 10°/s constant velocity were presented to the subjects in succession. In contrast to normal subjects, smooth pursuit eye movements in patients with ocular nerve palsies showed considerable differences in dependence on the fixating eye. The smooth pursuit gain of the paretic eye was reduced for eye movements in the pulling plane of the paretic muscle. When viewing with the paretic eye, the tracking of the target was achieved by a series of refixation saccades, which also occurred in the occluded normal eye. Consequently, the sound eye position overshot the target. The transition from a smooth to a saccadic pursuit pattern was accompanied by a spatial deviation of the eye movement trajectories from the path of the fixation target.

Neuro-ophthalmology of eye-movement disorders.

Magnetic resonance and functional brain imaging continue to expand their roles in complementing the clinical examination to localize the causes of eye-movement disorders. A retrospective review from county-based clinical practices emphasized generally benign causes of third, fourth, and sixth cranial nerve palsies in children, but a study from a tertiary referral center found a high incidence of neoplasms causing sixth-nerve palsies in children. A prospective study found that 38% of diabetic patients with third-nerve palsies had anisocoria up to 2.5 mm. An initial attempt to develop an evidence-based practice pathway for the evaluation of ocular motor nerve palsies has been developed for isolated sixth-nerve palsies in adults. In an important study of Graves hyperthyroidism, treatment with radioactive iodine was more likely than methimazole therapy alone to be associated with the appearance or worsening of ophthalmopathy. The clinical worsening of eye findings could be prevented by concurrent administration of corticosteroids for 3 months. Smoking is still a major controllable risk factor for thyroid ophthalmopathy.

Mandibular Contouring: A Surgical Technique for the Asymmetrical Lower Face

Correcting facial asymmetry is a difficult problem for plastic surgeons. From 1991 to 1996, the authors treated 53 cases of mandibular angle resection, 13 of which were of patients with an asymmetrical lower face. On the basis of these experiences, the authors highlight two important points in dealing with the asymmetrical lower face. The first is accurate resection of each side of the face. A cloth pattern was used to improve the accuracy of the procedure and to make the final result match the preoperative design regarding amount and shape. The second concerns soft-tissue change after the operation. Satisfactory results are obtained by the accurate resection of the bone coupled with the correct management of the surrounding soft tissue. The amount of bone to be resected was determined not simply by cephalometry, but by both cephalometry and external appearance. Postoperative cephalometry is not always symmetrical, and it is important that the final external appearance be harmonious and symmetrical. Using the above method, results have been satisfactory to both the surgeons and the patients, with the exception of three patients who had residual asymmetry. No permanent sensory loss or motor nerve palsy was observed, and no infections occurred.

Mandibular Contouring: A Surgical Technique for the Asymmetrical Lower Face

Correcting facial asymmetry is a difficult problem for plastic surgeons. From 1991 to 1996, the authors treated 53 cases of mandibular angle resection, 13 of which were of patients with an asymmetrical lower face. On the basis of these experiences, the authors highlight two important points in dealing with the asymmetrical lower face. The first is accurate resection of each side of the face. A cloth pattern was used to improve the accuracy of the procedure and to make the final result match the preoperative design regarding amount and shape. The second concerns soft-tissue change after the operation. Satisfactory results are obtained by the accurate resection of the bone coupled with the correct management of the surrounding soft tissue. The amount of bone to be resected was determined not simply by cephalometry, but by both cephalometry and external appearance. Postoperative cephalometry is not always symmetrical, and it is important that the final external appearance be harmonious and symmetrical. Using the above method, results have been satisfactory to both the surgeons and the patients, with the exception of three patients who had residual asymmetry. No permanent sensory loss or motor nerve palsy was observed, and no infections occurred.

Carotid disease and the eye.

Patients with carotid artery disease may present with monocular, ipsilateral ocular symptoms, and signs that can herald a devastating stroke. Asymptomatic retinal emboli, transient monocular visual loss, and central retinal artery occlusion are the most common. Venous stasis retinopathy and ocular ischemic syndrome are associated with severe hypoperfusion of the eye and usually reflect severe carotid occlusive disease. Embolic ischemic optic neuropathies and compression of the intracranial optic nerve by supraclinoid carotid arteries remain debated. Third-order Horner's syndrome and eye pain are common in carotid artery disease, particularly carotid dissection; carotid artery disease, however, is an uncommon cause of ocular motor nerve palsy. Several recent publications have highlighted the prognosis and management of patients with carotid artery occlusive disease, and have emphasized the role of the ophthalmologist in early diagnosis and prevention of further cerebral and systemic complications.

Clinical studies of ocular motility disturbances: Part 2. ischemic ocular motor nerve palsy risk factors

A case-control study of 46 Japanese patients who were diagnosed by exclusion as having ischemic ocular motor nerve palsy and who exhibited spontaneous recovery within 4 months was done to evaluate the risk factors involved. We also evaluated the association between the number of risk factors and the spontaneous recovery or recurrence periods. Ischemic ocular motor nerve palsy is closely related to diabetes mellitus and coronary artery disease. Patients tended to be obese; many had two or more risk factors. Aging, in combination with two or more risk factors, seems to increase the likelihood of developing this disease. Diabetes mellitus is a particularly significant risk factor for this type of palsy, especially in combination with hypertension.

Risk factors for ischemic ocular motor nerve palsies.

To identify risk factors associated with neurologically isolated ischemic ocular motor nerve palsies. Case-control study. Multispecialty clinic providing primary, secondary, and tertiary care in central and northern Wisconsin. After applying strict, predetermined, inclusion and exclusion criteria to the medical records of patients with ocular motor nerve palsies, 65 case patients 50 years of age or older were identified with ischemic ophthalmoplegia. A control subject, matched for sex and exact year of age, was randomly selected for each case patient from individuals undergoing a comprehensive medical evaluation. Prevalence of potential risk factors in case patients and controls, including diabetes, hypertension, hypercholesterolemia, coronary artery disease, left ventricular hypertrophy, adiposity, tobacco use, prior ocular motor nerve palsy, and hematocrit. Risk factors were assessed using standardized definitions. After adjustment for potential confounding factors, significant risk factors and their associated odds ratios (ORs) and 95% confidence intervals (CIs) were as follows: previously diagnosed diabetes, OR = 5.75 (CI = 1.68 to 19.7); left ventricular hypertrophy, OR = 5.20 (CI = 1.30 to 20.82); and, hematocrit (per percentage increase), OR = 1.35 (CI = 1.13 to 1.61). In addition to the generally accepted risk factor of diabetes, left ventricular hypertrophy and elevated hematocrit appeared to be important determinants of ischemic ocular motor nerve palsy. Additional studies should be undertaken to confirm these findings.

Isolated or predominant ocular motor nerve palsy as a manifestation of brain stem stroke.

There have been few reports of strokes producing isolated or predominant ocular motor nerve palsies as a clinical manifestation. We studied seven patients with brain stem stroke who had ocular motor palsies as the only or the predominant neurological manifestation, and we correlated their clinical features with radiological findings. Five patients had small strokes in the area of oculomotor nuclei or fascicles and showed various combinations of oculomotor disturbances. Three of these patients showed vertical gaze paresis of the opposite eye. One patient with a small hemorrhage near the aqueduct of Sylvius showed fourth nerve palsy on the contralateral side, and a patient with a small infarct in the pontine tegmentum showed isolated sixth nerve palsy. Nonocular minor neurological signs included trigeminal sensory changes in four patients and clumsy arm in two. Ocular and nonocular dysfunctions generally improved within several months. Radiological findings of the brain stem correlated well with the ocular signs. We conclude that acute brain stem stroke should be included in the differential diagnosis of isolated ocular motor nerve palsies and that appropriate diagnostic investigations should be performed in these cases.

Multiple cranial neuropathies: Presenting signs of systemic lymphoma

A 58-year-old man four years after orthototic liver transplantation presented with a mental neuropathy, multiple ocular motor nerve palsies, and an upper extremity motor neuropathy. Serial neuroimaging, cerebrospinal fluid analysis, total body computerized tomography and paraesophageal needle biopsy failed to reveal the underlying etiology. Sural nerve biopsy showed endoneurial perivascular infiltration with lymphoid cells, and bone marrow biopsy confirmed the diagnosis of a Burkitt's-type lymphoma. Systemic lymphoma with neural infiltration should be suspected in the immunosuppressed patient who presents with cranial or peripheral neuropathies.

Rate of Progression and Severity of Neuro-Ophthalmologic Manifestations of Cavernous Sinus Meningiomas

The progression of neuro-ophthalmologic signs and symptoms caused by cavernous sinus meningiomas (CSMs) was evaluated in 24 patients. Ten patients had primary involvement of the cavernous sinus by meningioma, and 14 patients had extension of a sphenoid ridge meningioma into the cavernous sinus. Eighteen patients were followed after intradural meningioma debulking. Two of these patients underwent conventional radiation therapy after surgery. The other six patients were followed without treatment. Optic neuropathy caused by extension of the CSM was the most frequently (67%) seen manifestation at the beginning of the follow-up period. Proptosis (50%), ocular motor nerve palsies (46%), and trigeminal neuropathy (33%) were also common. During a mean follow-up period of 57 months, 14 patients (58%) had no change in neurologic status, four patients (17%) had improvement in one or more parameters and six patients (25%) worsened. The patients who worsened had progression of preexisting cranial nerve palsies (two patients), developed new cranial neuropathies (three patients), or both (one patient). Patients who worsened had a significantly longer mean follow-up (76 months) than patients who remained stable or improved (47 months) (p = 0.01). Although the signs and symptoms of CSMs may worsen with time, the rate is slow and the degree is mild. These factors are important when considering treatment options.

Balloon occlusion of the internal carotid artery in 40 cases of giant intracavernous aneurysm: technical aspects, cerebral monitoring, and results.

We have studied the results of carotid occlusion in the treatment of giant intracavernous carotid artery (ICA) aneurysms in 40 patients. Clinical, angiographic, Doppler and cerebral blood flow (CBF) criteria for tolerance of occlusion are discussed. The patients had headaches (47.5%), cranial nerve compression (87.5%), decreased visual acuity (20%), ruptured aneurysm (15%) and 5% were asymptomatic. Balloon occlusion tests were performed under light sedation anaesthesia: a successful test required perfect clinical tolerance and adequate angiographic collateral circulation in arterial, parenchymatous, and venous phases. Additional criteria included xenon 133 CBF measurements, and transcranial Doppler sonography of the middle cerebral artery. According to these criteria, 5 patients did not tolerate test occlusion and required an extra-intracranial (EC-IC) bypass. Mean follow-up was 4.7 years. All patients were radiologically cured of their aneurysm, and in 35 the symptoms resolved, although 3 had persistent ocular motor nerve palsies, and in 4 visual defects were unchanged. Complications were 1 permanent and 3 transient neurological deficits. Balloon occlusion of the ICA is an effective, reliable form of treatment for intracavernous giant aneurysm and should replace surgical ligation of the cervical carotid artery. With CBF or Doppler monitoring, the risk of neurological deficit is diminished. EC-IC bypass prior to ICA occlusion is indicated if test occlusion is not tolerated.

Herpes Reactivation and Ophthalmoplegia From Pituitary Adenoma Invading the Cavernous Sinus

Ocular motor nerve palsies are common in patients with herpesvirus reactivation. The palsies are caused by an ischemic vasculitis affecting the ocular motor nerves along with the trigeminal nerve. On rare occasions, a tumor in the cavernous sinus can produce ophthalmoplegia and skin manifestations of herpesvirus infection. Report of a Case. —An 82-year-old man was found by a family member to be mildly confused and complaining of right orbital pain. On examination he had a fever of 39.8°C and herpetic vesicles on the right side of the nose and upper lip. Skin testing disclosed mild hypoesthesia involving the right ophthalmic (V1) and maxillary (V2) trigeminal divisions. Visual acuity was 20/20 OU. The patient was unable to open his right eye (Fig 1). It was completely ophthalmoplegic with a fixed 6.5-mm pupil. The patient's ophthalmoplegia was initially attributed to herpesvirus. However, a computed tomographic scan performed 2 days later

Incidence of Recurrent Ocular Motor Nerve Palsies

A review of the case notes of 600 patients who had attended the Ocular Motility Clinic at St Paul's Eye Hospital in Liverpool between 1976 and 1990 revealed 19 cases of recurrent ocular motor nerve palsies. Recurrent isolated single nerve palsies without other neurological involvement occurred in 12 patients and accounted for 42 of a total of 51 palsies. All recovered completely with a mean duration of 3.00 months. Five were non-insulin dependent diabetics and two had a pre-diabetic curve on glucose tolerance testing. Five patients were labelled as benign, cause unknown.Involvement of two or more cranial nerves, or other neurological signs were present in seven patients with a total of nine palsies. Three of these failed to recover and one recovered only partially. Excluding these, the mean duration of the five palsies which did recover was 5.5 months. There were two cases of cerebro-vascular accident and two of multiple sclerosis and one each of trigeminal schwannoma, ophthalmoplegic migraine, and cause ...

Clinicopathological correlation in a case of painful ophthalmoplegia: Tolosa-Hunt syndrome.

A case of painful ophthalmoplegia due to idiopathic granulomatous involvement of the superior orbital fissure (Tolosa-Hunt syndrome) is described. The clinical features of recurrent pain, ocular motor nerve palsies and proptosis correlated well with the eventual demonstration of an enhancing mass in the region of the cavernous sinus. Removal of the lesion led to a resolution of the clinical picture and demonstration of a non-caseating granuloma with no other detectable cause. The original observation of Tolosa was thus re-affirmed.