Third Nerve Palsy Research Articles

Management Approaches and Patient Outcomes for Giant Pituitary Neuroendocrine Tumors Classified as Knosp Grade 3 and 4.

Background Treatment of patients with a giant pituitary neuroendocrine tumor (GPitNET) is challenging. Here, we present the methods used for the clinical management of patients who underwent GPitNET resection mainly via endoscopic endonasal surgery along with multimodal supportto avoid surgical complications, which can affect the outcomes. Methodology The medical records of 25 patients with a GPitNET who underwent endonasal endoscopic surgery were retrospectively reviewed. Complications were analyzed and factors affecting the extent of resection were evaluated. Results Gross total resection was achieved in six (24%), near-total resection (>90%) in nine (36%), and partial resection in 10 (40%) patients. Multivariate analyses revealed that tumors invading the middle fossa had negative effects on the extent of resection (odds ratio = 0.092, p = 0.047). Postoperative vision improved or normalized in 16 (64%), remained stable in eight (32%), and worsened in one (4%), while a new hormonal deficit was noted in seven (28%) patients. Complications included permanent oculomotor nerve palsy in one (4%) and transient oculomotor palsy in one (4%), apoplexy of the residual tumor resulting in ischemic stroke in one (4%), postoperative cerebrospinal fluid leakage in one (4%), and permanent diabetes insipidus in six (24%) patients. Conclusions For GPitNETs that extend into the middle fossa, our study underscored the difficulties in surgical extraction and the necessity for tailored treatment approaches. To ensure the safest and most complete removal possible, the surgical strategy must be specifically adapted to each case. Additionally, employing a comprehensive support approach is essential to reduce the chance of complications in patients impacted by this condition.

Anatomical aberration of posterior part of circle of Willis with special reference to third nerve palsy

Due to the close anatomical proximity, aneurysm of posterior communicating artery may cause oculomotor nerve palsy, which is a common manifestation and it may present with pupil involving extra ocular muscle paresis. The onset may be acute due to sudden aneurysm dissection along with subarachnoid hemorrhage. This may warrant urgent lifesaving surgical intervention along with the options of interventional radiological procedures.Normally, the occipital lobe is supplied by the posterior cerebral artery (PCA). When the pre-communicating portion of the PCA is larger than the posterior communicating artery (PCA), the occipital lobe is primarily supplied by the vertebrobasilar artery. Sometimes the pre-communicating portion of the PCA may be smaller than the PCoA in which the occipital lobe is primarily supplied by the internal carotid artery.Understanding the posterior circulation anomalies of Circle of Willis. This study involved 50 fetal brains belonging to perinatal age group and 30 adult brains of human cadavers by dissection. The PCoA was missing in 14% of the samples. The difference between the outer diameters of the P1 portion of the PCA and the PCoA was very significant.So, a detailed anatomical understanding of Circle of Willis and manifestation of the third nerve palsy is sometimes equivocal for a clinician for better management and patient outcome.

Prediction for the prognosis of diffuse axonal injury using automated pupillometry

ObjectivePrevious studies have reported various predictive indicators of diffuse axonal injury (DAI), but no consensus has not been reached. Although the efficiency of automated pupillometry in patients with consciousness disorder has been widely reported, there are few reports of its use in patients with DAI. This study aimed to investigate the significance of pupillary findings in predicting the prognosis of DAI. Patients and MethodsWe included patients admitted to our center with a diagnosis of DAI from June 1, 2021 to June 30, 2022. Pupillary findings in both eyes were quantitatively measured by automated pupillometry every 2 hours after admission. We statistically examined the correlations between automated pupillometry parameters, the patients’ characteristics, and outcomes such as the Glasgow Outcome Scale Extended (GOSE) after 6 months from injury, the time to follow command, and so on. ResultsAmong 22 patients included in this study, five had oculomotor nerve palsy. Oculomotor nerve palsy was correlated with all outcomes, whereas Marshall computed tomography (CT) classification, Injury severity score (ISS) and DAI grade were correlated with few outcomes. Some of the automated pupillometry parameters were significantly correlated with GOSE at 6 months after injury, and many during the first 24 hours of measurement were correlated with the time to follow command. Most of these results were not affected by adjustment using sedation period, ISS or Marshall CT classification. A subgroup analysis of patients without oculomotor nerve palsy revealed that many of the automated pupillometry parameters during the first 24 hours of measurement were significantly correlated with most of the outcomes. The cutoff values that differentiated a good prognosis (GOSE 5–8) from a poor prognosis (GOSE 1–4) were constriction velocity (CV) 1.43 (AUC = 0.81(0.62–1), p = 0.037) and maximum constriction velocity (MCV) 2.345 (AUC = 0.78 (0.58–0.98), p = 0.04). The cutoff values that differentiated the time to follow command into within 7 days and over 8 days were percentage of constriction 8 (AUC = 0.89 (0.68–1), p = 0.011), CV 0.63 (AUC = 0.92 (0.78–1), p = 0.013), MCV 0.855 (AUC = 0.9 (0.74–1), p = 0.017) and average dilation velocity 0.175 (AUC = 0.95 (0.86–1), p = 0.018). ConclusionsThe present results indicate that pupillary findings in DAI are a strong predictive indicator of the prognosis, and that quantitative measurement of them using automated pupillometry could facilitate enhanced prediction for the prognosis of DAI.

Clinical experience of professor ZHANG Ren in the staging treatment with characteristic acupuncture techniques for oculomotor paralysis.

The paper summarizes the clinical experience of professor ZHANG Ren in the staging treatment with characteristic acupuncture techniques for oculomotor paralysis. According to the symptoms of oculomotor paralysis, the staging treatment is given, in which acupuncture is dominant and the needling techniques are optioned in compliance with the symptoms. In the early, middle and late stages of illness, three different acupuncture therapies are delivered accordingly, i.e. the combination of the point-toward-point needling at the four acupoints located on the forehead and the electroacupuncture with disperse-dense wave, the surrounding needling and the triple needling at the acupoints around the eyeball, as well as the perpendicular needle insertion at the three acupoints within the orbit. Professor ZHANG Ren lays the stress on identifying the etiology and differentiating the symptoms, as well as the early intervention for the disease. For the intractable cases, the comprehensive regimen such as acupoint injection, dermal needling and auricular point sticking is supplemented. During treatment, the spirit harmonization is greatly considered to ensure the effectiveness. On the basis of the staging acupuncture therapy, the acupuncture technique for harmonizing the spirit and regulating qi is combined to obtain the favorable clinical effect on oculomotor paralysis.

Teaching NeuroImage: Metastatic Urachal Carcinoma in the Extraocular Muscles Mimicking Oculomotor Paralysis.

Teaching NeuroImage: Metastatic Urachal Carcinoma in the Extraocular Muscles Mimicking Oculomotor Paralysis.

Correlation between clinical and neuropathological subtypes of progressive supranuclear palsy

IntroductionProgressive supranuclear palsy (PSP) is characterized by pathology prominently in the basal ganglia, the tegmentum of the brainstem, and the frontal cortex. However, pathology varies according to clinical features. This study aimed to statistically verify the correspondence between the clinical and pathological subtypes of PSP. MethodsWe identified patients with a pathological diagnosis of PSP and classified the eight clinical subtypes of the Movement Disorders Society criteria for the clinical diagnosis of PSP (MDS-PSP criteria) into the Richardson, Akinesia, and Cognitive groups. We used anti-phosphorylated tau antibody immunostaining to semi-quantitatively evaluate neurofibrillary tangles (NFTs) and coiled bodies/threads (CB/Ths) in the globus pallidus, subthalamic nucleus, and midbrain tegmentum. In the frontal cortex, tufted astrocytes (TAs) and CB/Ths were assessed on a 3-point scale. We compared the pathology among the three groups, recorded the phenotypes ranked the second and lower in the multiple allocation extinction rule and examined whether the pathology changed depending on applying each phenotype. ResultsThe Richardson group exhibited severe NFTs and CB/Ths in the midbrain tegmentum. The Akinesia group showed severe NFTs in the globus pallidus. The Cognitive group had severe TAs and CB/Ths in the frontal cortex. TAs and CB/Ths in the frontal cortex correspond to behavioral variant frontotemporal dementia, and supranuclear vertical oculomotor palsy. ConclusionThese clinical symptoms may reflect the distribution of tau pathologies in PSP.

Surgical management of oculomotor nerve palsy: a comparison of lateral rectus deactivation combined with either medial rectus resection or medial rectus fixation to the medial palpebral ligament

PurposeTo analyze and compare the outcome of two different surgical procedures in patients with complete oculomotor nerve palsy with large-angle exotropia. MethodsThe medical records of patients with total oculomotor nerve palsy and large-angle exotropia operated on at a single center from January 2006 to June 2020 were reviewed retrospectively. One group underwent lateral rectus deactivation with medial rectus resection (resection group); the other group underwent lateral rectus deactivation with medial rectus fixation to the medial palpebral ligament (fixation group). Surgical outcomes on the first postoperative day and at 6 months postoperatively were analyzed, including alignment and postoperative complications. All statistical analyses were performed using STATA version 14. A P value of <0.05 was considered significant. ResultsA total of 35 patients were included. There was a trend toward greater surgical success in the fixation group (93%) than in the resection group (65%), but these results were not statistically significant. Postoperative exotropic drifts were noted in both the procedures but tended to be more with patients in the resection group. Postoperative complications were noted only in the fixation group. ConclusionsLateral rectus deactivation with medial rectus fixation to the medial palpebral ligament requires more time and greater surgical expertise but appears to better prevent postoperative exotropic drift compared with lateral rectus deactivation combined with medial rectus resection.

A case of pituitary apoplexy presented with isolated complete oculomotor nerve palsy

The oculomotor nerve (CN3) innervates four extra-ocular muscles and contains parasympathetic fibers controlling pupillary light reflex (PLR). CN3 palsy with impaired PLR or complete CN3 palsy usually suggests a compressive lesion against the CN3 because the parasympathetic fibers located superficially on the cranial nerve trunk are affected. A cerebral aneurysm originated from posterior communicating artery, posterior cerebral artery or superior cerebellar artery is a common cause of isolated complete CN 3 palsy. Here, we reported a less common intracranial lesion causing isolated complete CN3 palsy for which the preceding recurrent temporal headaches before the CN3 palsy assisted the neurological localization.

Usefulness of Opening the Diaphragma Sellae Before Transecting Interclinoidal Ligament for Endoscopic Endonasal Transoculomotor Triangle Approach: Technical Nuances and Surgical Outcomes

Opening the oculomotor triangle and removing the posterior fossa lesion by endoscopic endonasal approach (EEA) is challenging for even an experienced endoscopic neurosurgeon. We summarize the treatment experience and technical nuances with EEA for resection of pituitary neuroendocrine tumors and cavernous sinus (CS) meningiomas invading through the oculomotor triangle (OT). Between 2018 and 2022, eight cases, including five pituitary neuroendocrine tumors (PitNET) including three nonfunctioning and two somatotroph tumors with elevated growth hormone, and 3 CS meningiomas were treated using an endoscopic endonasal transoculomotor triangle approach. The critical surgical technique is continuously opening the diaphragma sellae from medial to lateral towards the interclinoidal ligament (ICL) and transecting it to enlarge the OT. We evaluated preoperative tumor size, previous surgical history, preoperative symptoms, extent of tumor resection, histopathology, and postoperative complications for all patients. The GTR(gross total resection)- defined as complete removal in 3 patients (38%), near-total resection(NTR) - defined as >95% removal in 4 patients (50%), and subtotal resection (STR)- defined as up to 90 % removal in one patient (12%)and gross-total resection of tumor invading through the OT was achieved in all patients through pure EEA. Two of three patients with visual deficit in Non-Functioning-PitNET improved, and the other remained stable postoperatively. One patient showed transient oculomotor nerve palsy. The Growth Hormone level of the two patients with somatotroph tumors declined to normal. For three patients with CS meningiomas, cranial nerve palsy improved in two patients, while the other patient developed increased facial numbness after surgery. Endoscopic endonasal transoculomotor triangle approach is an efficient surgical option for the tumor with CS invasion and OT penetration.

Nursing of a patient with oculomotor nerve paralysis treated with plum-blossom needle tapping therapy

Nursing of a patient with oculomotor nerve paralysis treated with plum-blossom needle tapping therapy

Etiological distribution of isolated oculomotor nerve palsy: analysis of 633 patients and literature review.

The etiological distribution of oculomotor nerve palsy has varied amongst the studies. This study aimed to define the clinical features and underlying etiologies of isolated oculomotor nerve palsy by recruiting patients from all departments in a referral-based university hospital. The medical records of 672 patients who had a confirmed diagnosis of isolated oculomotor nerve palsy at all departments of Seoul National University Bundang Hospital, Seongnam, South Korea, from 2003 to 2020 were reviewed. A proportion of the etiology of isolated oculomotor nerve palsy was also compared with that of patients pooled from the previous studies that were searched on PubMed in May 2022. The most common etiology was microvascular (n = 168, 26.5%), followed by vascular anomalies (n = 110, 17.4%), neoplastic (n = 86, 13.6%), inflammatory (n = 79, 12.5%), idiopathic (n = 60, 9.5%) and traumatic (n = 53, 8.4%). Neurologists were mainly involved in the management of microvascular and inflammatory oculomotor nerve palsies whilst ophthalmologists mainly participated in the care of idiopathic, neoplastic and traumatic palsies. Neurosurgeons mostly took care of oculomotor nerve palsy due to vascular anomalies. The proportion of etiologies of isolated oculomotor nerve palsy may differ according to the specialties involved in the management. The results of previous studies on the etiological distribution of isolated oculomotor nerve palsy should be interpreted with this consideration.

Surgical management of oculomotor nerve palsy - a review of the literature.

We aim to review the surgical management techniques available for patients with oculomotor nerve (OMN) palsy, compare and contrast the approaches and subsequent outcomes. A search of the literature was carried out to yield all papers relevant to the topic, and a wide spectrum of surgical techniques were identified. These included: muscle shortening and lengthening procedures, muscle transposition, globe fixation and ptosis surgery. Patients often require a synergistic combination of these techniques. Strabismus surgery for OMN palsy can be approached through a variety of different techniques to improve the quality of life, independence and aesthetics for the patient.

The challenge of controlling an auditory BCI in the case of severe motor disability

BackgroundThe locked-in syndrome (LIS), due to a lesion in the pons, impedes communication. This situation can also be met after some severe brain injury or in advanced Amyotrophic Lateral Sclerosis (ALS). In the most severe condition, the persons cannot communicate at all because of a complete oculomotor paralysis (Complete LIS or CLIS). This even prevents the detection of consciousness. Some studies suggest that auditory brain–computer interface (BCI) could restore a communication through a « yes–no» code.MethodsWe developed an auditory EEG-based interface which makes use of voluntary modulations of attention, to restore a yes–no communication code in non-responding persons. This binary BCI uses repeated speech sounds (alternating “yes” on the right ear and “no” on the left ear) corresponding to either frequent (short) or rare (long) stimuli. Users are instructed to pay attention to the relevant stimuli only. We tested this BCI with 18 healthy subjects, and 7 people with severe motor disability (3 “classical” persons with locked-in syndrome and 4 persons with ALS).ResultsWe report online BCI performance and offline event-related potential analysis. On average in healthy subjects, online BCI accuracy reached 86% based on 50 questions. Only one out of 18 subjects could not perform above chance level. Ten subjects had an accuracy above 90%. However, most patients could not produce online performance above chance level, except for two people with ALS who obtained 100% accuracy. We report individual event-related potentials and their modulation by attention. In addition to the classical P3b, we observed a signature of sustained attention on responses to frequent sounds, but in healthy subjects and patients with good BCI control only.ConclusionsAuditory BCI can be very well controlled by healthy subjects, but it is not a guarantee that it can be readily used by the target population of persons in LIS or CLIS. A conclusion that is supported by a few previous findings in BCI and should now trigger research to assess the reasons of such a gap in order to propose new and efficient solutions.Clinical trial registrations: No. NCT02567201 (2015) and NCT03233282 (2013).

Wall permeability on magnetic resonance imaging is associated with intracranial aneurysm symptoms and wall enhancement.

Wall remodeling and inflammation accompany symptomatic unruptured intracranial aneurysms (UIAs). The volume transfer constant (Ktrans) of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) reflects UIA wall permeability. Aneurysmal wall enhancement (AWE) on vessel wall MRI (VWI) is associated with inflammation. We hypothesized that Ktrans is related to symptomatic UIAs and AWE. Consecutive patients with UIAs were prospectively recruited for 3-T DCE-MRI and VWI from January 2018 to March 2023. UIAs were classified as asymptomatic and symptomatic if associated with sentinel headache or oculomotor nerve palsy. Ktrans and AWE were assessed on DCE-MRI and VWI, respectively. AWE was evaluated using the AWE pattern and wall enhancement index (WEI). Spearman's correlation coefficient and univariate and multivariate analyses were used to assess correlations between parameters. We enrolled 82 patients with 100 UIAs (28 symptomatic and 72 asymptomatic). The median Ktrans (2.1 versus 0.4min-1; p < 0.001) and WEI (1.5 versus 0.4; p < 0.001) were higher for symptomatic aneurysms than for asymptomatic aneurysms. Ktrans (odds ratio [OR]: 1.60, 95% confidence interval [95% CI]: 1.01-2.52; p = 0.04) and WEI (OR: 3.31, 95% CI: 1.05-10.42; p = 0.04) were independent risk factors for symptomatic aneurysms. Ktrans was positively correlated with WEI (Spearman's coefficient of rank correlation (rs) = 0.41, p < 0.001). The combination of Ktrans and WEI achieved an area under the curve of 0.81 for differentiating symptomatic from asymptomatic aneurysms. Ktrans may be correlated with symptomatic aneurysms and AWE. Ktrans and WEI may provide an additional value than the PHASES score for risk stratification of UIAs. The volume transfer constant (Ktrans) from DCE-MRI perfusion is associated with symptomatic aneurysms and provides additional value above the clinical PHASES score for risk stratification of intracranial aneurysms. • The volume transfer constant is correlated with intracranial aneurysm symptoms and aneurysmal wall enhancement. • Dynamic contrast-enhanced and vessel wall MRI facilitates understanding of the pathophysiological characteristics of intracranial aneurysm walls. • The volume transfer constant and wall enhancement index perform better than the traditional PHASES score in differentiating symptomatic aneurysms.

Peri-operative stroke: isolated oculomotor palsy following Hartmann's procedure

Peri-operative stroke: isolated oculomotor palsy following Hartmann's procedure

Intracisternal Papaverine-Induced Oculomotor Palsy during Anterior Circulation Aneurysm Surgery: A Report of Five Cases and Literature Review

Intracisternal Papaverine-Induced Oculomotor Palsy during Anterior Circulation Aneurysm Surgery: A Report of Five Cases and Literature Review

Unusual presentation of Chronic Subdural hematoma as Isolated Oculomotor palsy

Isolated oculomotor palsy (ONP) is an unusual presentation in chronic subdural hematomas (CSDH) and is very rare as an initial manifestation. Most commonly, ONP is caused by ischemic microangiopathy, posterior communicating artery aneurysm, uncal herniation, neoplasia, traumatic and/or any inflammatory conditions. ONP in chronic subdural hematoma is a sign of cerebral herniation that is typically associated with a deterioration of consciousness. We describe a case of chronic subdural hematoma that presented with an isolated ONP.

The profiles and clinical significance of extraocular muscle-expressed lncRNAs and mRNAs in oculomotor nerve palsy.

Oculomotor nerve palsy (ONP) arises from primary abnormalities in the central neural pathways that control the extraocular muscles (EOMs). Long non-coding RNAs (lncRNAs) have been found to be involved in the pathogenesis of various neuroparalytic diseases. However, little is known about the role of lncRNAs in ONP. We collected medial rectus muscle tissue from ONP and constant exotropia (CXT) patients during strabismus surgeries for RNA sequencing analysis. Differentially expressed mRNAs and lncRNAs were revealed and included in the functional enrichment analysis. Co-expression analysis was conducted between these differentially expressed mRNAs and lncRNAs, followed by target gene prediction of differentially expressed lncRNAs. In addition, lncRNA-microRNA and lncRNA-transcription factor-mRNA interaction networks were constructed to further elaborate the pathological changes in medial rectus muscle of ONP. Furthermore, RT-qPCR was applied to further validate the expression levels of important lncRNAs and mRNAs, whose clinical significance was examined by receiver operating characteristic (ROC) curve analysis. A total of 618 differentially expressed lncRNAs and 322 differentially expressed mRNAs were identified. The up-regulated mRNAs were significantly related to cholinergic synaptic transmission (such as CHRM3 and CHRND) and the components and metabolism of extracellular matrix (such as CHI3L1 and COL19A1), while the down-regulated mRNAs were significantly correlated with the composition (such as MYH7 and MYL3) and contraction force (such as MYH7 and TNNT1) of muscle fibers. Co-expression analysis and target gene prediction revealed the strong correlation between MYH7 and NR_126491.1 as well as MYOD1 and ENST00000524479. Moreover, the differential expressions of lncRNAs (XR_001739409.1, NR_024160.1 and XR_001738373.1) and mRNAs (CDKN1A, MYOG, MYOD1, MYBPH, TMEM64, STATH, and MYL3) were validated by RT-qPCR. ROC curve analysis showed that lncRNAs (XR_001739409.1, NR_024160.1, and NR_002766.2) and mRNAs (CDKN1A, MYOG, MYOD1, MYBPH, TMEM64, and STATH) might be promising biomarkers of ONP. These results may shed light on the molecular biology of EOMs of ONP, as well as the possible correlation of lncRNAs and mRNAs with clinical practice.

Clinical and diagnostic profile of Tolosa-Hunt syndrome; a 7-year retrospective observational study.

Tolosa Hunt Syndrome (THS) was first delineated in 1954 and is caused by a granulomatous inflammation in the cavernous sinus, superior orbital fissure or orbit. In this study the different clinical and diagnostic findings of THS are discussed. Case records of patients diagnosed with THS using the International Classification of Headache Disorders 3rd edition criteria from January 2016-July 2022 were considered for the current study. Demographic, Clinical, Laboratory and Radiological data of all patients fulfilling the inclusion and exclusion criteria was collected from the patient case records through the Medical Records Department of BMCRI Super Specialty Hospital. A total of 60 patients were included in the study with mean age with SD, 50.9 years (13.9) and were predominantly male (66.6%). Restriction of eye movements was the most common symptom affecting 31 (51.7%) patients. Oculomotor nerve (IIIrd Cranial Nerve) palsy was the most common nerve palsy, affecting 36 (60%) patients. Contrast enhancing lesions or T2/FLAIR Hyper-intense areas were seen in the Magnetic Resonance Imaging (MRI) of 59 (98.3%) patients. Cavernous sinus involvement, was the most common site of involvement, in 25 (41.6%) of the patients. All patients were treated with intravenous methyl prednisolone injections and responded well. Restriction of eye movements was the most common symptom, along with cavernous sinus being the most common site of involvement in THS. MRI scans are important diagnostic tools for THS.

Impact of Diplopia and Ptosis From Lingering Third Nerve Palsy After Treatment of Cerebral Aneurysms.

Third nerve palsies (TNPs) may not resolve after intervention for intracranial aneurysms that have compressed the nerve. The disability related to this lingering condition has not been assessed with the support of patient self-report. A single-institutional retrospective study of patients with TNP who had undergone interventions for intracranial aneurysms. We used residual primary-position diplopia, a narrow zone of single binocular vision, and vision-obscuring ptosis to divide TNP recovery into complete, incomplete nondisabling, and incomplete disabling outcomes based on medical record documentation and patient self-report derived from telephonic interviews. In a cohort of 33 patients, 13 (39%) had complete TNP recovery. There were 11 patients (33%) with lingering visual disability from diplopia or ptosis present before ophthalmic interventions. Of the 6 patients who underwent ophthalmic interventions, visual disability was relieved in only 2 patients, leaving 9 patients (27%) with lingering impairment in instrumental activities of daily living. Telephonic interviews of 23 patients (70% of the cohort) confirmed that the outcome criteria we applied were accurate in assessing visual disability in 17 patients (74%). Univariate analysis using the Fisher exact test showed that aneurysmal clipping as a treatment modality was the only clinical feature associated with a favorable TNP outcome. In applying a novel method of assessing disability, this study showed that more than one-quarter of patients undergoing procedures for brain aneurysms had lingering disability from third nerve palsy-associated diplopia or ptosis, despite later ophthalmic interventions. Patient self-report gleaned from telephonic interviews was valuable in largely validating the assessment method derived from medical records and in revealing differences between physician and patient estimation of disability.