Oculomotor Nerve Dysfunction Research Articles

Posterior Ethmoid Sinus Mucocele Complicated With Oculomotor Nerve Dysfunction.

Posterior Ethmoid Sinus Mucocele Complicated With Oculomotor Nerve Dysfunction.

Predictive factors of the postoperative proptosis recovery in surgery of spheno-orbital meningiomas.

This study aimed to identify factors affecting proptosis recovery in spheno-orbital meningioma (SOM) surgery and assess functional and oncological outcomes. Data from 32 consecutive SOM surgery cases (2002-2021) were analyzed. Clinical, radiological, operative, and oncological parameters were examined. Proptosis was assessed using the exophthalmos index (EI) on MRI or CT scans. Statistical analyses were performed to identify predictive factors for proptosis recovery. Proptosis improved in 75% of patients post-surgery (EI decreased from 1.28 ± 0.16 to 1.20 ± 0.13, p = 0.048). Patients with stable or worsened EI had higher body mass index (28.5 ± 7.9 vs. 24.1 ± 4.7, p = 0.18), Simpson grade (IV 75% vs. 65%, p = 0.24), and middle sphenoid wing epicenter involvement (63% vs. 38%, p = 0.12), but no significant factors were associated with unfavorable exophthalmos outcomes. The improvement group had higher en plaque morphology, infratemporal fossa invasion, and radiation treatment for cavernous sinus residual tumor (88% vs. 75%, p = 0.25; 51% vs. 25%, p = 0.42; 41% vs. 25%, p = 0.42, respectively), but without statistical significance. Visual acuity remained stable in 78%, improved in 13%, and worsened in 9% during follow-up. Surgery had a positive impact on preoperative oculomotor nerve dysfunction in 3 of 4 patients (75%). Postoperative oculomotor nerve dysfunction was observed in 25%, of which 75% fully recovered. This occurrence was significantly associated with irradiation of an orbital tumor residue (p = 0.04). New postoperative trigeminal hypoesthesia was observed in 47%, of which 73% recovered. All SOMs were classified as WHO grade 1, and complementary treatments achieved oncological control, requiring gamma-knife radiosurgery in 53% and standard radiotherapy in 6%. Surgery effectively improves proptosis in SOM, though complete resolution is rare. The absence of predictive factors suggests multifactorial causes, including body mass index and tumor resection grade. Postoperative oculomotor nerve dysfunction and trigeminal hypoesthesia are common but often recover. Gamma-knife radiosurgery maintains long-term oncological control for evolving tumor residue.

Hard to see: Systemic lupus erythematous presenting as cranial nerve six palsy: A Case Report

Systemic Lupus Erythematous (SLE) is an autoimmune disease that can affect multiple organs and can have a wide variety of symptomatic presentations. One rare presenting symptom is oculomotor nerve dysfunction, the following case report is of a 41-year-old female with a past medical history of hypertension and asthma, who was admitted for ocular dysfunction. On physical examination, the patient had an ocular palsy, but the rest of the neurological exam was unremarkable. Imaging modalities such as computed tomography (CT) scan head without contrast, brain magnetic resonance imaging, and computed tomography angiography (CTA) of the head and neck revealed no acute pathology. After a neurological etiology was excluded an autoimmune diagnosis was pursued. Lab results were positive for Anti-Smith, ANA, and Anti-DsDNA. The patient also at this time was also diagnosed with an acute kidney injury and a kidney biopsy that was done later revealed focal lupus nephritis. After starting immunosuppressive therapy, her symptoms improved.

S1969 Treatment of Refractory ICI-Associated Colitis With Fecal Microbiota Transplant

Introduction: The clinical benefits of immune checkpoint inhibitors (ICIs) have been associated with immune-related adverse events (irAEs), with ICI-associated colitis among the most reported. ICI-associated colitis is routinely treated with immunosuppressive therapy, including corticosteroids and anti-TNF agents. Recent studies have suggested fecal microbiota transplant as a potential treatment for refractory ICI-associated colitis. Case Description/Methods: Middle aged female with multiple sclerosis in remission and stage IV melanoma with bone and pulmonary involvement who was first diagnosed about 3 years ago. She underwent palliative radiation followed by 4 cycles of ipilimumab and nivolumab initially. Despite this therapy she had cancer progression. She was then started on treatment with cisplatin, vinblastine and dacarbazine (CVD), however she failed to respond. She was switched to targeted therapy with encorafenib and binimitinib. Within 2 months, she was admitted to the hospital with anemia and hypotension, endoscopic evaluation revealed multiple intestinal and colonic ulcers. Based on these findings she was suspected to have ICI enterocolitis and received 2 cycles of infliximab plus high dose corticosteroids. She resumed encorafenib and binimitinib after clinical improvement and started single agent nivolumab. She was readmitted within 3 months and again at 4 months after for anemia and melena despite receiving additional treatment with vedolizumab and multiple courses of high dose corticosteroids. She was then treated with ustekinumab; however, she was again hospitalized a fourth time for similar symptoms. Decision was made to treat her refractory colitis with fecal microbiota transplant (FMT) as compassionate use. She had a remarkable response, with complete resolution of her GI symptoms with no additional immunosuppressive therapy or hospitalizations. However, patient’s cancer continued to progress. Her course was further complicated by oculomotor nerve dysfunction and ultimately was transitioned to hospice care and passed away 4 months later (Figure). Discussion: Fecal microbiota transplant has emerged as novel therapeutic option for treatment of refractory ICI-associated colitis. Combination treatment with ICI and targeted therapy may be a risk factor for more severe colitis with significant ulcers and refractory disease course. Further studies are needed to assess the risk factors related to combination therapy and guide more effective treatment.Figure 1.: A: Altered anatomy near cecum, B: Ulcer in terminal ileum, C: Ulcerated mass in ascending colon, D: Ascending colon narrowing.

Predictors of visual function after resection of skull base meningiomas with extradural anterior clinoidectomy

Skull base meningiomas threatening the optic nerves may require performing an extradural anterior clinoidectomy (EAC) to optimally decompress the optic pathways. The present study evaluated the functional results and morbidity after surgical resection of skull base meningiomas including EAC, focusing on visual acuity (VA) and oculomotricity. Eighty-seven consecutive patients harboring skull base meningiomas who underwent surgical resection that included an EAC between 2003 and 2020 were retrospectively analyzed (86% women, median age 53years). Decreased visual acuity (DVA) was graded as functional (VA ≥ 5/10) and nonfunctional (VA < 5/10). Statistical analyses were performed on VA and oculomotor nerve (OcN) dysfunction. Ninety surgical procedures were performed. Meningiomas were located at the anterior clinoid process (39%), cavernous sinus (31%), and spheno-orbital (30%) levels. Patients with a preoperative functional vision (normal or functional DVA) had a 90.9% (IC95% = [84.0; 97.8]) probability of preserving it at 6months and an 84.8% (IC95% = [76.2; 93.5]) probability at last follow-up. Patients with preoperative nonfunctional vision (nonfunctional DVA or blindness) had a 19.0% (IC95% = [2.3; 35.8]) probability of recovery of functional vision at 6months and a 23.8% (IC95% = [5.6; 42.0]) probability at last follow-up. Preoperative DVA was significantly associated with early postoperative DVA in univariate analyses (p = 0.04). Concerning the OcN, 65% of the patients experienced a postoperative dysfunction, and 78% of those cases recovered. Our study confirms EAC as a useful technical option for skull base meningiomas threatening the optic nerve, especially relevant for patients with preoperative functional vision, and supports early surgical management for these meningiomas.

Recovery of oculomotor nerve palsy after endovascular management of posterior communicating artery aneurysms.

BackgroundOculomotor nerve palsy (ONP) is a common clinical presentation of posterior communicating artery (PcomA) aneurysms. It remains unclear if patients have a better rate of recovery after surgical clipping or endovascular coiling.ObjectivesThe main objectives of this study were to assess the overall rate of ONP recovery after endovascular coiling of PcomA aneurysms, as well as to determine the associated predictive factors of oculomotor nerve recovery.MethodWe retrospectively evaluated the demographic, clinical, and radiological characteristics and the outcome of consecutive patients presenting with PcomA aneurysms treated by endovascular coiling from January 2012 to November 2016 with at least 1 year clinical and radiological follow-up. Statistical analysis was applied to determine the association between ONP recovery and the demographic, clinical and radiological variables.ResultsA total of 91 patients with PcomA aneurysms were treated endovascularly. Thirty-four patients (22 women and 12 men) with ONP related to PcomA aneurysms were included. The mean age of the patients was 49.8 years. Subarachnoid haemorrhage was present in 27 patients. The mean aneurysm size was 6.7 mm. The overall rate of recovery was 88.2%. Complete nerve recovery was seen in 16 (47%) patients and partial recovery was observed in 14 (41.2%) patients, whilst 4 (11.8%) patients remained unchanged after treatment. The non-posterolateral direction of the aneurysm showed a tendency towards better recovery compared to the posterolateral projection (p = 0.06).ConclusionEndovascular coiling of PcomA aneurysms in patients with ONP resulted in a cure or improvement of oculomotor nerve dysfunction in the majority of patients.

Unilateral Oculomotor Nerve Dysfunction Induced by Ruptured Anterior Communicating Artery Aneurysm along with Isolated Intraventricular Hemorrhage in a Trauma Patient

Background: Many signs in relation to vascular events and consequent loss of consciousness could be easily incorrectly explained (unclear) in a setting of trauma, especially when these events are a result of the car accident. Third cranial nerve palsy widely occurs due to internal carotid and posterior communicating artery aneurysm. An anterior communicating(ACOM) aneurysm is a rare reason that could lead to oculomotor dysfunction. ACOM ruptured aneurysm may present with sub arachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH) but isolated IVH is a rare finding for ACOM ruptured aneurysm. Case Description: A 56-year-old male presented to the hospital emergency department because of trauma after a car accident. He was unconscious with left-sided dilated pupil and ptosis with a brain CT indicating IVH. Brain CT angiography that performed two weeks after the accident revealed ACOM aneurysm. The patient underwent craniotomy and clipping the aneurysm. He was discharged, after completing the period of the following treatmentA combination of neuropathic agents and opioids helped to control pain. These analgesic included amitriptyline, gabapentin, pregabalin, tramadol and morphine in various regimens. Paracetamol and ibuprofen were also used. Conclusion: This report is a unique case of synchronization of third cranial nerve palsy and isolated IVH without SAH due to ACOM aneurysm. In addition, it could be interesting to re-emphasize the need for a comprehensive assessment of traumatic patients for finding some primary pathologies, which could result in an accident.

ENDOSCOPIC INTRAVENTRICULAR HEMORRHAGE REMOVAL: CLINICAL OBSERVATION AND TECHNICAL FEATURES

The study objective is to describe a successful endoscopic therapy for a patient with hypertensive ventricular hemorrhage complicated by occlusive third ventricular hydrocephalus. Materials and methods. A 71-year-old patient with hypertensive hemorrhage into the III and IV ventricles, complicated by non-communicating hydrocephalus, was brought to hospital on the 1st day of the disease onset. Non-communicating hydrocephalus was accompanied by clinical signs of decompensation, depressed level of consciousness up to moderate coma (Glasgow Coma Scale score of 7). Specialists performed emergency endoscopic aspiration of blood clots from the III and IV ventricles and third ventriculostomy. Results. Endoscopically it was possible to remove the clots from the third ventricle and through the cerebral aqueduct from the fourth ventricle. Resuscitation and intensive care measures resulted in a favorable outcome: the patient was released with a moderate neurological deficit – left oculomotor nerve dysfunction. After 4 months, the patient required a ventriculoperitoneal shunt due to disresponsive form of hydrocephalus. Conclusion. Endoscopic aspiration allows removing hematomas from the third and fourth ventricles via the lateral ventricle effectively and safely.

Endovascular treatment of carotid-cavernous vascular lesions.

to evaluate the endovascular treatment of vascular lesions of the cavernous segment of the internal carotidartery (ICA) performed at our institution. we conducted a descriptive, retrospective and prospective study of patients with aneurysms of the cavernous portion of the ICA or with direct carotid-cavernous fistulas (dCCF) undergoing endovascular treatment. we included 26 patients with intracavernous aneurysms and ten with dCCF. All aneurysms were treated with ICA occlusion. Those with dCCF were treated with occlusion in seven cases and with selective fistula occlusion in the remaining three. There was improvement of pain and ocular proptosis in all patients with dCCF. In patients with intracavernous aneurysms, the incidence of retro-orbital pain fell from 84.6% to 30.8% after treatment. The endovascular treatment decreased the dysfunction of affected cranial nerves in both groups, especially the oculomotor one. the endovascular treatment significantly improved the symptoms in the patients studied, especially those related to pain and oculomotor nerve dysfunction. avaliar o tratamento endovascular de lesões vasculares da artéria carótida interna (ACI), segmento cavernoso, realizado na Santa Casa de São Paulo. estudo descritivo, retrospectivo e prospectivo, de pacientes com aneurisma da porção cavernosa da ACI ou com fístulas carótido-cavernosas diretas (FCCd) submetidos a tratamento endovascular. foram incluídos 26 pacientes com aneurismas intracavernosos e dez com FCCd. Todos os aneurismas foram tratados com oclusão da ACI. Os com FCCd foram tratados com oclusão, em sete casos, e com oclusão seletiva da fístula nos outros três. Houve melhora da dor e proptose ocular em todos os pacientes com FCCd. Nos pacientes com aneurisma intracavernoso, a incidência de dor retro-orbitária caiu de 84,6% para 30,8% após o tratamento. Após o tratamento endovascular houve uma melhora importante da disfunção de nervos cranianos afetados em ambos os grupos, sobretudo no nervo oculomotor. o tratamento endovascular trouxe melhora para os pacientes deste estudo, especialmente nos critérios dor e acometimento do nervo oculomotor.

Electrical stimulation promotes regeneration of injured oculomotor nerves in dogs.

Functional recovery after oculomotor nerve injury is very poor. Electrical stimulation has been shown to promote regeneration of injured nerves. We hypothesized that electrical stimulation would improve the functional recovery of injured oculomotor nerves. Oculomotor nerve injury models were created by crushing the right oculomotor nerves of adult dogs. Stimulating electrodes were positioned in both proximal and distal locations of the lesion, and non-continuous rectangular, biphasic current pulses (0.7 V, 5 Hz) were administered 1 hour daily for 2 consecutive weeks. Analysis of the results showed that electrophysiological and morphological recovery of the injured oculomotor nerve was enhanced, indicating that electrical stimulation improved neural regeneration. Thus, this therapy has the potential to promote the recovery of oculomotor nerve dysfunction.

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.

Endovascular treatment of the carotid-cavernous vascular lesions

Introduction: The treatment of lesions which compromise the cavernous sinus has always constituted a challenge. The endovascular treatment of these lesions has presented diverse alterations over the last years. This study aims to evaluate the endovascular treatment of vascular lesions in the internal carotid artery (ICA), cavernous segment, performed at our service. Method: This is a descriptive study, retrospective and prospective. Patients with aneurysm in the cavernous ICA or direct carotid-cavernous fistula (dCCF) submitted to endovascular treatment were evaluated. Results: Included were 26 patients with intracavernous aneurysms and 10 with dCCF. All aneurysms were treated with ICA occlusion. The dCCF were treated with occlusion of the ICA in seven cases and with selective fistula occlusion in the remaining three. There was an improvement in pain and ocular proptosis in all patients with dCCF. In the patients with intracavernous aneurysms, the incidence of retroorbitary pain went from 84.6% to a mere 30.8%, following the treatment. Following endovascular treatment, there was an important improvement in the dysfunction of cranial nerves, compromised in both patient groups, mainly in the oculomotor nerve. Conclusion: The endovascular treatment provided an improvement in the patients of this study, especially in the criteria pain and oculomotor nerve dysfunction.

Factors Predicting the Oculomotor Nerve Palsy following Surgical Clipping of Distal Vertebrobasilar Aneurysms: A Single-Institution Experience.

Background The aim of our study was to identify various clinical and radiologic factors that correlate with the oculomotor nerve palsy following clipping of distal vertebrobasilar aneurysms. Methods A total of 48 patients with 51 aneurysms were included in this retrospective study . Patient's age, gender, size, location, and projection of the aneurysm, preoperative Hunt and Hess (H&H) grade, presence of subarachnoid hemorrhage (SAH), temporary clipping, preoperative third nerve palsy, and Glasgow Outcome Scale were included in the model for analysis. Results A total of 15 patients (31.25%) developed oculomotor nerve palsy following clipping of basilar apex aneurysms. 38 patients (79.2%) presented with SAH and 35 patients (72.9%) had poor H&H grades at presentation. The size of the aneurysm (p = 0.03), preoperative H&H grade (p = 0.04), preoperative oculomotor nerve dysfunction (p = 0.007), and projection of an aneurysm (p = 0.004) had shown a significant correlation with the oculomotor nerve palsy. The size of the aneurysm (p = 0.030, odds ratio: 0.381; 95% confidence interval, 0.175-0.827] was an independent predictor of postoperative nerve dysfunction. Conclusion The size of the aneurysm, clinical grade at presentation, and projection of the aneurysm correlated with the oculomotor nerve dysfunction following clipping. These clinical and radiologic parameters can be used to predict the oculomotor nerve outcome.

Insertion of the dorsal oblique muscle in the dog: an anatomic basis for ventral strabismus associated with oculomotor nerve dysfunction

To describe the insertion of the dorsal oblique (DO) muscle in relationship to the equator of the globe in dogs. The study was conducted on 10 fresh cadaver eyes from five dogs, which were euthanized for disease processes unrelated to ocular disease. A manual vernier caliper was used to determine the calculated measurements. The median anterior-to-posterior diameter of the globe was 21 mm. The median length from the vertex of the anterior pole to the anterior point of insertion of the DO tendon was 11.5 mm. The median length from the posterior pole to the posterior point of insertion of the DO tendon was 10 mm. The width of tendon of insertion of the DO tendon was 3.25 mm. In disorders involving the oculomotor nerve or the oculomotor nerve nucleus in the mesencephalon, the resultant strabismus is directed ventrolaterally. Based on the insertion of the superior oblique muscle in humans, we hypothesized that the DO muscle would likely explain the ventral deviation in disorders of the oculomotor nerve or its nucleus. In this study, the point of the insertion of the DO muscle tendon was posterior to the equator. Based on this anatomic location, unopposed function of the DO muscle would be expected to result in ventral deviation of the globe.

Recovery of posterior communicating artery aneurysm-induced oculomotor nerve paresis after endovascular treatment

ObjectiveRecovery of aneurysm-induced oculomotor nerve paresis (ONP) after endosaccular coiling has not yet been adequately assessed. The aim of this study was to investigate the factors that affect the outcome of ONP after endovascular treatment of posterior communicating artery (PcomA) aneurysms. Materials and methodsWe retrospectively evaluated the clinical characteristics and the outcome of oculomotor nerve function in a series of 36 patients with ONP due to PcomA aneurysms treated by endovascular coiling. Univariate analysis was applied to test the association between ONP recovery and clinical variables. ResultsThirty-six consecutive patients (20 women, 16 men; mean age, 54.3±9 years) presenting with ONP underwent endosaccular coiling were enrolled in this study. Subarachnoid hemorrhage was present in 21 patients. The mean size of the aneurysms was 9.3±3.9mm. ONP was complete in 14 patients (38.9%) and partial in 22 patients (61.1%) at admission. Seventeen patients (47.2%) had complete recovery of oculomotor nerve function, 15 had incomplete recovery (41.7%), and 4 (11.1%) remained unchanged after treatment. Factors showing significant association with recovery of oculomotor nerve function were the length and degree of ONP before treatment (P=0.035 and P=0.019, respectively). ConclusionsEndosaccular coiling of PcomA aneurysms in patients with ONP resulted in cure or improvement of oculomotor nerve dysfunction in the majority of patients. The length and degree of preoperative ONP were the statistically significant predictors of complete ONP recovery.

Diffuse large B-cell lymphoma within a cavernous hemangioma of the cavernous sinus

Cavernous angiomas or hemangiomas and malignant lymphomas rarely involve the cavernous sinus. We report the case of a 72-year-old man with right circumorbital pain and right oculomotor nerve dysfunction because of a mass in the right cavernous sinus. It was removed via a transsphenoidal approach and histological examination revealed the mass was a cavernous hemangioma containing atypical large B cells in some sinusoidal vessels; no other evidence of lymphoma was detected on (18)F-2-fluoro-2-deoxy-D-glucose positron-emission tomography or bone marrow biopsy. The patient underwent gamma knife radiosurgery (GKS) of the right cavernous sinus, but no systemic chemotherapy was administered. Although good local control was achieved, the patient developed a systemic diffuse large B-cell lymphoma (DLBCL) 1.5 years after the GKS. The atypical lymphocytes of the cavernous hemangioma and biopsied lymph nodes expressed multiple myeloma oncogene-1 protein. This is a rare case of DLBCL occurring within a cavernous sinus that was diagnosed as hemangioma of the cavernous sinus by neuroimaging, surgical findings, and rapid-freezing histological diagnosis. The case indicates a importance of surgical sampling and detailed histopathological analysis.

Magnetic resonance angiography and clinical evaluation of third nerve palsies and posterior communicating artery aneurysms

The authors conducted a study to determine the utility of the clinical profile and magnetic resonance (MR) angiography in evaluating patients with isolated third cranial nerve palsies or posterior communicating artery (PCoA) aneurysms. Three-dimensional time-of-flight MR angiography was performed in a consecutive series of patients with isolated acute third cranial nerve palsy not due to a ruptured aneurysm and in patients with unruptured PCoA aneurysms. A neuroradiologist, masked to the identities of the patients, interpreted reformatted maximum intensity projection (MIP) and source images of the PCoAs and aneurysms. The investigators assessed clinical features of oculomotor nerve dysfunction and focal head pain. Cases involving cranial third nerve palsy without aneurysms were classified as Group 1 (no case entailed catheter-based angiography), and cases involving PCoA aneurysms seen on MR angiography (42 cases confirmed by catheter-based angiography) were classified as Group 2. The mean age of the 73 patients in Group 1 was 60.1 years and that of the 45 patients in Group 2 was 59.1 years (p = 0.37). The pattern and severity of oculomotor (p = 0.61) and lid (p = 0.83) dysfunction and pain frequency (p = 0.2) were similar for the 73 patients with vasculopathy in Group 1 and the 15 symptomatic patients in Group 2. Abnormal pupils were observed in 38% of the patients in Group 1 and 80% of those in Group 2 (p = 0.016). In cases of complete external third nerve palsy, nine of 22 in Group 1 and none of four in Group 2 had normal pupil function. For all patients, source imaging showed 206 PCoAs (85%) and MIP imaging demonstrated 120 PCoAs (49%). Of 48 aneurysms (three bilateral), MIP imaging showed 44 (92%) and source imaging showed 47 (98%). Only a 2-mm aneurysm seen on catheter-based angiography was missed by MR angiography. Symptomatic aneurysms were equal or greater than 4 mm in size. Only the presence of complete external third nerve palsy and normal pupil function allowed ischemia to be clinically distinguished from a PCoA aneurysm in a patient with isolated third nerve palsy and no subarachnoid hemorrhage. When source image MR angiography demonstrates normal findings, catheter-based angiography need not be performed in these patients, even if pupil function is abnormal.

Evolution of oculomotor nerve paresis after endovascular coiling of posterior communicating artery aneurysms: a neuro-ophthalmological perspective.

Guglielmi detachable coil treatment is becoming an accepted alternative to microsurgical clipping for select intracerebral aneurysms. Resolution of oculomotor nerve paresis (ONP) after endovascular packing was claimed to be complete in two prior series, with three and six cases. We describe the evolution of ONP after Guglielmi detachable coil treatment of posterior communicating artery aneurysms, and we search for endovascular and patient factors correlated with the degree of functional nerve recovery. Twelve cases of ONP attributable to posterior communicating artery aneurysms were treated with Guglielmi detachable coils between 1999 and 2002. Eleven patients were available for follow-up monitoring. The degree of ONP was recorded at admission, at discharge, after 3 months, and at yearly intervals thereafter. The size of the aneurysm, the duration of ONP before coiling, the degree of coiling, age, and the presence of other microvascular risk factors were correlated with the degree of nerve recovery. Complete resolution of ONP did not occur in any of the 11 cases in this series. However, residual oculomotor nerve deficits did not cause diplopia with primary gaze for 10 of 11 patients. Clinically significant ptosis did not persist for any of the patients. The pupil remained minimally affected in all cases. Although mass effect remains after endovascular packing, oculomotor nerve dysfunction improves comparably to the recovery observed after surgical clipping. Contrary to previous reports, typical residual oculomotor nerve deficits persist. Older age and the presence of microvascular risk factors seem to be detrimental to ONP recovery.

Bilateral orbital signs predict cortical venous drainage in cavernous sinus dural AVMs. Steibel-Kalish H, Setton A, Berenstein A, Kalish Y, Nimii Y, Kupersmith MJ. Neurology 2002;58:1521-1524.

Cavernous sinus dural arteriovenous malformations (CSdAVM) cause a spectrum of ophthalmic signs and symptoms ranging from a purely ocular or orbital syndrome to less common aggressive neurologic dysfunction due to intracerebral hemorrhages or cerebral venous infarction. Most CSdAVMs have a benign clinical course, but those that drain into cortical veins have an increased risk for neurologic complications. The objective of this study was to determine whether a specific clinical sign predicts cortical venous drainage in CSdAVMs. The records of 118 patients with CSdAVMs were evaluated for the clinical features of the disorder and tested for predictive value of cortical venous drainage. Clinical signs that predicted the presence of cortical venous drainage included bilateral orbital signs (P = 0.004 OR = 23.84) and presence of a postauricular bruit (P = 0.035 odds ratio (OR) = 23.8). No other clinical sign predicted the presence of cortical venous drainage, including extraocular muscle dysfunction, abducens or oculomotor nerve dysfunction, increased intraocular pressure, venous stasis retinopathy, chroroidal effusion, optic neuropathy, subjective bruit, and objective orbital bruit. The authors concluded that patients who present with or develop bilateral orbital congestion from CSdAVMs should be recognized as being at increased risk for cortical venous drainage and venous infarction. These patients should have a contrast-enhanced MRI scan and be considered strongly for timely cerebral angiography and endovascular therapy if cortical venous drainage is found.—Nancy J. Newman

Isolated oculomotor nerve palsy due to neoplasm in infancy

A nine-month-old infant presenting with an isolated oculomotor nerve dysfunction was found to have a poorly differentiated neoplasm of the mesencephalon, an unusual presentation of an unusual tumor. Acquired, isolated, third cranial nerve palsy in a child poses a challenging differential diagnosis. Although tumor is a rare cause of this finding, full evaluation for malignancy is warranted in such a case.