Partial Palsy Research Articles

Isolated Vertical Ophtalmoplegia and Mydriasis Due to Bilateral Midbrain Infarction

Partial fascicular oculomotor palsy, the combination of bilateral midriasis with loss of vertical gaze movements, is rarely a consequence of midbrain infarction. We describe a patient with acute ischemic infarcts involving both upper most part of the midbrain, presenting with marked vertical gaze palsy and mydriasis bilaterally as the only neurological abnormality. These features are suggestive of partial fascicular oculomotor palsies involving the pupil, inferior rectus(IR), superior rectus(SR), inferior oblique(IO) muscles and sparing medial rectus(ML), levator palpebrae(LP) muscles. These neuro-ophthalmological and radiological findings in our case support the model that the fibers to medial rectus and levator palpebrae muscles might be located in the more caudal portion of the oculomotor fascicles.

Viral mononeurities causing partial oculomotor nerve palsy in an 8 month old child.

BACKGROUND:Palsy of the oculomotor nerve is rarely seen in children, and comprehensive guidelines for management and outcome are difficult to find.CASE:Here we describe a 8 month old boy with left sided ptosis and infero-leteral deviation of left eye and normally reacting pupil and CSF antimeasles antibody titre negative.OUTCOME:The ptosis improved within 3 weeks with no residual neurodeficit.MESSAGE:Viral mononeuritis leading to partial 3rd nerve palsy is a rare entity in children till date.

Bilateral ptosis without upward gaze palsy: Unusual presentation of midbrain tuberculoma

Central nervous system tuberculoma can have variable presentations depending on the site and number of tuberculomas. We are reporting a rare case of an 11-year-old male child presenting with ptosis and ataxia. Clinical examination revealed bilateral partial 3rd cranial nerve palsy (ptosis without any upward gaze palsy) associated with dysdiadochokinesia and ataxia on the right side. Magnetic resonance imaging of the brain revealed a single ring-enhancing lesion in the dorsal midbrain with perifocal edema. Magnetic resonance spectroscopy provided the etiological information as tuberculoma.

A Case of Coincidental Intrasellar Chordoma and Pituitary Adenoma.

Although chordomas are midline tumors, primarily intrasellar chordomas are extremely rare. In this report, the authors describe the case of a 68-year-old female with partial abducens nerve palsy in the right eye due to the intrasellar cystic tumor. After endonasal trans-sphenoidal surgery, intraoperative and histopathological findings confirmed the co-occurrence of an entirely intrasellar chordoma and pituitary adenoma. To our knowledge, the present case is the third reported case of an intrasellar chordoma with a pituitary adenoma.

Total hip arthroplasty for fused hips: clinical and radiological outcome

Background Hip fusion restricts most of daily-living activities, and patients request takedown of their fusion hoping to improve gait and function and relieve pain from adjacent joints. Patients and methods We retrospectively reviewed 27 fused hips (22 patients) converted to total hip arthroplasty between 2001 and 2013. A total of 19 male and three female patients had hip fusion for an average of 17 years (range: 6–32), with mean age at conversion of 34 years (range: 22–55). The etiology of fusion was surgical arthrodesis in seven, ankylosing spondylitis in 12, post-traumatic in four, dysplasia in two, and idiopathic in two hips. Posterolateral approach was used in all patients with intraoperative imaging to guide in-situ neck osteotomy and ensure correct positioning of the cup. A total of 18 hips were uncemented, with ceramic-on-ceramic bearing used in 11. Results Patients were followed for a mean of 96 months (range: 36–168). Center of rotation was restored to within 0.5 cm in 24 hips. Limb-length discrepancy averaging 1 cm (range: 0.5–2 cm) was noted in six patients. Harris hip score improved significantly from 46 (range: 20–56) to 78 (range: 42–97) at the last follow-up with a mean flexion range of 85° (65–120°). Abductor lurch with positive Trendelenburg sign was present in eight hips. All but two patients were satisfied with the result. One cup was aseptically loose, making for 96% implant survival. Complications also included two cases of heterotypic ossification, one partial sciatic nerve palsy that later recovered, and one hematoma formation. No dislocations or wound infections were reported. Conclusion Successful takedown of hip fusion is possible with improved function and gait and low complication rate.

Moebius syndrome

AbstractMoebius syndrome is a rare congenital disorder involving complete or partial palsy of cranial nerve VII. Other cranial nerves can also be involved along with limb and orofacial malformations. This case report describes and discusses the clinical manifestations and briefly highlights management options for a patient diagnosed with Moebius syndrome.

Reconstruction of the Shallow Acetabulum With a Combination of Autologous Bulk and Impaction Bone Grafting Fixed by Cement

BackgroundAcetabular bone deficiency, especially proximal and lateral deficiency, is a difficult technical problem during primary total hip arthroplasty (THA) in developmental dysplasia of the hip (DDH). We report a new reconstruction method using a medial-reduced cemented socket and additional bulk bone in conjunction with impaction morselized bone grafting (additional bulk bone grafting method).Questions/purposesIn a population of patients with acetabular dysplasia undergoing THA using a medial-reduced cemented socket and additional bulk bone with impacted morselized bone grafting, we evaluated (1) the radiographic appearance of bone graft; (2) the proportion of cups that developed loosening and subsequent revision; and (3) clinical results (outcome scores and complications).MethodsForty percent of 330 THAs for DDH performed at one center between 1999 and 2009 were defined as shallow dysplastic hips. The additional bulk bone grafting method was performed on 102 THAs with shallow acetabulum (31% for DDH) at one center between 1999 and 2009. We used this approach and technique for shallow acetabuli when a cup protruded from the lateral acetabular edge in preoperative templating. The other 132 dysplastic hips without bone grafting had THA performed at the same periods and served as a control. Acetabuli were defined as shallow when the depth was less than or equal to one-fifth of the pelvic height (cranial-caudal length on radiograph). The additional bulk bone grafting technique was as follows: the resected femoral head was sectioned at 1 to 2 cm thickness, and a suitable size of the bulk bone graft was placed on the lateral iliac cortex and fixed by poly-l-lactate absorbable screws. Autologous impaction morselized bone grafting, with or without hydroxyapatite granules, was performed along with the implantation of a medial-reduced cemented socket. We defined an “incorporated” graft as remodeling and trabeculation including rounding off of the protruding edge of a graft beyond the socket. Radiographic criteria used for determining loosening were migration or a continuous radiolucent zone between the prosthesis/bone cement and host bone. Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) and the Merle d’Aubigne and Postel score; complications were tallied from chart review. The followup was 10 ± 3 years (range, 6–15 years).ResultsOne acetabular component (1%) with severe shallow and steep acetabuli showed definite radiographic evidence of loosening and was revised. Clinically, the mean JOA score for the hips treated with additional bulk bone grafting THA in this study improved from 39 ± 10 points preoperatively to 95 ± 5 points postoperatively (p < 0.05, paired t-test). The mean Merle d’Aubigne and Postel score for the hips improved from 7 ± 2 points to 17 ± 1 points (p < 0.05, paired t-test). Complications included a Trendelenburg sign in one hip, dislocation in one, and transient partial sciatic nerve palsy in one. Within 3 years 6 months postoperatively, 101 of 102 additional bulk bone grafting cases showed successful bone remodeling and bone graft reorientation without collapse on radiographs. Partial resorption of the additional bone graft on the lateral side was observed in two hips (2%) with socket abduction angles of < 35°.ConclusionsAchieving stable acetabular fixation is often challenging in the dysplastic hip, especially shallow acetabulum, and a variety of techniques have been described. Early results of combining bulk graft with impaction of morselized graft are promising. Although each surgical technique was well established, further investigation for clinical results of a combination of these techniques might be necessary to confirm longer term outcomes.Level of EvidenceLevel IV, therapeutic study.

Rhomboid nerve transfer to the suprascapular nerve for shoulder reanimation in brachial plexus palsy: A clinical report

Recovery of shoulder function is a real challenge in cases of partial brachial plexus palsy. Currently, in C5–C6 root injuries, transfer of the long head of the triceps brachii branch is done to revive the deltoid muscle. Spinal accessory nerve transfer is typically used for reanimation of the suprascapular nerve. We propose an alternative technique in which the nerve of the rhomboid muscles is transferred to the suprascapular nerve. A 33-year-old male patient with a C5–C6 brachial plexus injury with shoulder and elbow flexion palsy underwent surgery 7 months after the injury. The rhomboid nerve was transferred to the suprascapular nerve and the long head of the triceps brachii branch to the axillary nerve for shoulder reanimation. A double transfer of fascicles was performed, from the ulnar and median nerves to the biceps brachii branch and brachialis branch, respectively, for elbow flexion. At 14 months’ follow-up, elbow flexion was rated M4. Shoulder elevation was 85 degrees and rated M4, and external rotation was 80 degrees and rated M4. After performing a cadaver study showing that transfer of the rhomboid nerve to the suprascapular nerve is technically possible, here we report and discuss the clinical outcomes of this new transfer technique.

Pupil-sparing third nerve palsies and hemiataxia: Claude’s and reverse Claude’s syndrome

We report two patients with midbrain infarction with pupil-sparing third nerve palsies and hemiataxia: one with contralateral ataxia (Claude’s syndrome) and one with ipsilateral ataxia (which we refer to as reverse Claude’s syndrome). We highlight the importance of a thorough neurologic evaluation with partial oculomotor palsies and describe, to our knowledge, the fourth account in the literature of a pupil-sparing third nerve palsy with ipsilateral cerebellar ataxia.

Paralisias parciais idiopáticas do interósseo posterior – 8 casos

IntroductionIdiopatic partial palsies of the posterior interosseous nerve are rare, probably caused by compression at the distal part of the supinator muscle. Material and methodWe saw 8 cases in the last 10 years, 5 of the thumb and 3 of some fingers only, none evolving to complete palsies. Results2 cases of the thumb, seen early, recovered spontaneously. Of the other 6 cases, seen late, 4 had paliative surgery with good results ‐ 2 thumbs, one 4th‐5th fingers and another 3th‐4th fingers. 2 patients refused surgery ‐ one thumb and one 4th finger. ConclusionIdiopatic partial palsies of the posterior interosseous nerve do exist and must be diagnosed from extensor tendon ruptures. Some recover spontaneously. For those that do not recover, late paliative surgery can give good results.

The spectrum of ocular motor abnormalities as the only clinical sign of brainstem lesions

Background The widespread use of magnetic resonance imaging (MRI) revealed an increasing variety of ocular motor abnormalities as the only clinical sign of (mainly ischemic) brainstem lesions. Methods This paper reviews the variety of such abnormalities. Results Ocular motor abnormalities as the only clinical sign of MRI-documented brainstem lesions include complete and partial 3rd, 4th and 6th nerve palsies, vertical gaze palsies, crossed vertical gaze palsy, monocular elevation paresis, internuclear ophthalmoplegia, horizontal gaze palsy, horizontal gaze palsy with facial palsy, 1 1 2 -syndrome, 1 1 2 -syndrome with facial palsy (“ 8 1 2 -syndrome”), upbeat nystagmus, horizontal-rotatory nystagmus, horizontal nystagmus, skew deviation, and ocular tilt reaction. Conclusions Brainstem lesions causing isolated ocular motor abnormalities may be divided into 4 main groups. (A) Lesions involving infranuclear ocular motor nerve segments cause complete and partial 3rd, 4th and 6th nerve palsies. (B) Lesions affecting nuclei related to eye movements such as 3rd and 6th nerve nucleus, rostral interstitial nucleus of the medial longitudinal fasciculus, interstitial nucleus of Cajal, nucleus intercalatus Staderini are followed by horizontal and vertical gaze palsies, upbeat nystagmus, horizontal-rotatory nystagmus. (C) Lesions interrupting internuclear connections lead to internuclear ophthalmoplegia, monocular elevation paresis, skew deviation and ocular tilt reaction. (D) Combined lesions of nuclear and internuclear or infranuclear structures are the anatomical basis of 1 1 2 -syndrome, 8 1 2 -syndrome, or horizontal gaze palsy with facial palsy. The clinical significance of these disorders is not known.

Universal Bypass for Treatment of Symptomatic Moyamoya Disease or Moyamoya Syndrome. Analysis of a Personal Case Series on Behalf of the Italian Moyamoya Association.

Moyamoya (MM) is a very rare cerebrovascular disease, particularly in Caucasians. We describe the results of an Italian case series where the mainstay of treatment was a bypass or a combined approach. An analysis of a prospectively collected database was carried out. The main objective was to investigate (1) the risk of perioperative stroke and surgical complications, (2) the risk of new ischemic events, and (3) the risk of new hemorrhages at follow-up (mean follow-up: 2.2 years). Between January 2011 and January 2015 we carried out 34 bypasses in 23 patients with MM (15 MM disease, 5 unilateral MM, 3 MM syndrome); mean age was 34 (range:1-57). The mortality and definitive morbidity rates were 0 %. Two patients suffered from transient aphasia and one developed partial palsy of the facial nerve. Five of the 12 patients with preoperative fixed deficits improved. No patient with preoperative ischemia experienced new ischemic symptoms. Rebleeding occurred in 1 of the 11 patients with a hemorrhagic presentation (9 %). The bypass/combined approach to MM appears to have a favorable risk profile and preventive effectiveness, particularly on TIAs and ischemic stroke.

Total transposition combined with with resection of superior and inferior rectus muscles in the treatment of complete 6th cranial nerve palsy

Data source: • Retrospective chart review • All patients undergoing surgery for complete CN 6 (CN6) palsy by two surgeons (MDM and SA) at Kellogg Eye Center from January 1, 1985 and August 1, 2014. Inclusion criteria: • Complete CN6 palsy • Any etiology • Age between 6 months and 99 years • Managed with full tendon vertical rectus muscle transpositions with Foster-Augmentation or resection of vertical rectus muscles prior to transposition Exclusion criteria (Figure 1): • Graves eye disease • Prior transposition procedure on involved eye • Bilateral transpositions • Partial CN6 palsy • Brain stem depression • Staged procedure or simultaneous surgery on other extraocular muscles

Functional Outcomes of Nerve Reconstruction in Severe Obstetric Brachial Plexus Palsy

Background Microsurgical era has brought a renewed interest in the management of birth-related brachial plexus palsy. There is a general agreement that severe obstetric palsy should be treated by an early nerve reconstruction. Patients and Methods This report is an experience in the primary nerve reconstruction in 32 cases of obstetric brachial plexus lesions in the age group 3.5 to 23 months. Parietal injuries were most commonly associated with truncal neuromas. Conducting neuromas were subjected to neurolysis, whereas nonconducting neuromas were treated by resection and nerve grafting. Restoration of hand functions was a priority in total lesions. In total palsy, a viable root stump if available was connected with nerve grafts to the distal nerve, primarily targeted toward the hand, and nerve transfers were performed for shoulder and elbow. Results A total of 20 patients had C5, C6 injuries and 5 had an associated C7 injury. Seven patients presented with total palsy. The follow-up period ranged from 14 to 42 months. Patients with partial palsy and early surgical intervention produced good functional results in relation to the elbow and shoulder. Recovery in hand function in total palsy was satisfactory to poor. Conclusion Microsurgical reconstruction is indicated for those infants who fail to recover antigravity biceps flexion by 4 to 6 months of age. An early intervention by 3 months is desirable in total palsy.

A systematic review of peroneal nerve palsy and recovery following traumatic knee dislocation.

A common peroneal nerve (CPN) palsy has been reported to complicate knee dislocations in 5-40% of patients. Patients who suffer from a persistent foot drop have significantly worse functional outcomes. Reports on prognostic factors for nerve recovery or treatment-specific functional outcomes remain sparse in the literature. Two independent reviewers completed a search of Medline, Embase, PubMed and the Cochrane Library from 1946 to present. Motor strength was determined using the Medical Research Council (MRC) grading system or an equivalent description. A functional recovery was defined as an MRC ≥3/5. The combined search of Medline, Embase, PubMed and the Cochrane Library identified 1528 abstracts. Thirteen articles met our inclusion/exclusion criteria. This included 214 CPN palsies. Functional recovery (MRC ≥3/5) following complete CPN palsy was 38.4%. Full recovery (MRC=5/5) following partial CPN palsy was 87.3%. Younger age was predictive of neurologic recovery. Recovery following isolated neurologic interventions ranged from 0 to 30%. A vastly different prognosis can be expected for patients who suffer an incomplete versus a complete CPN palsy. The majority of patients with an incomplete palsy will achieve a full motor recovery while <40% of patients with a complete motor palsy will regain the ability to dorsiflex at the ankle. While neurologic interventions show promise for the future, the outcomes in knee dislocation patients remain poor. The most predictable means of reestablishing antigravity dorsiflexion in a persistent CPN palsy is a posterior tibial tendon transfer.

Recent advances clarifying the etiologies of strabismus.

Strabismus is commonly encountered in neuro-ophthalmology practice. Adult patients may present with symptoms including disabling diplopia and decreased quality of life. Although presentation to the neuro-ophthalmologist often prompts a thorough workup for a neurologic basis of ocular misalignment, advances in orbital imaging and understanding of orbital mechanics have revealed novel mechanical causes. A goal of this review is to clarify mechanical mechanisms of strabismus that were formerly assumed be neurologic in origin. The authors combine their own research and clinical experience with a literature review using PubMed. Aberrant paths of the extraocular muscles can lead to strabismus. The extraocular muscles have connective tissue pulleys that control muscle paths and are, in turn, influenced by the extraocular muscle orbital layers. Orbital connective tissues, including the pulleys, constrain extraocular muscle paths. Abnormalities of these tissues may lead to strabismus that is not due to neurologic pathology. Some extraocular muscles are divided into independent neuromuscular compartments, so that partial motor nerve lesions may manifest as selective denervation of only 1 compartment, complicating the presentation of neuropathic strabismus. Strabismus in adults due to nonneurologic causes can result from recently described abnormalities of the orbital connective tissue pulley system. Advances in understanding of compartmental extraocular muscle anatomy and innervation can explain cyclovertical strabismus in partial nerve palsies. Recognition of the underlying pathogenesis of the strabismus can lead to improved treatments.

How late is too late for nerve transfers

Traditionally, the degeneration of the motor endplates has placed a limit on the accepted delay for nerve reconstruction. Nerve transfers have helped to deliver growing axons very close to the target muscles so that the post-operative denervation is shortened. Despite efforts at spreading awareness of surgical indications, there are instances where the patient presents late to a specialized brachial plexus unit. In such cases, one faces the dilemma of using traditional nerve transfers or opting for a free functioning muscle transfer. Some surgeons rely on the presence of fibrillations on the EMG to help them decide about the feasibility of re-innervation. However, there are no clear guidelines. I would like to present a study of 50 patients operated at 9 months or later (9-19.5 months) from the accident. I have excluded cases operated later than April 2013, as the follow-up is too short. Their ages ranged from 4-57 years with a mean of 28.6 years (31 of the 50 patients belonged the range 10-30 years). There were 15 total palsies, 15 cases of C567 palsies, 9 cases of C56 palsies, one case of isolated C8T1 involvement and 10 infraclavicular palsies (injuries beyond the trunks). Among the nerve transfers for elbow flexion, intercostals were transferred to the musculocutaneous in 15 cases. Biceps of at least grade 3 strength was restored in 5/15 patients. Ulnar to biceps transfer was done in 22 cases (+median to brachialis in 16 of these). 17 of these patients regained elbow flexion stronger than grade 3. The spinal accessory nerve was transferred to the suprascapular nerve in 34 cases and grade 3 supraspinatus was achieved in 20 patients. However, the cases of successful restoration of shoulder abduction included 7 patients with C56 palsies and 4 of C567 palsies. Thus, from these observations it appears that: 1. In total palsies, the failure rate of intercostals to musculocutaneous and spinal accessory to suprascular nerve transfers is far higher than the overall average in my series. 2. The failure rate for ulnar to biceps transfer remains unchanged even up to 19.5 months from the accident. 3. Shoulder abduction is a reasonable expectation after a nerve transfer in a partial palsy even at delays longer than 10 months. I recommend that one should not succumb to the temptation to perform traditional nerve reconstruction in patients with flail upper limbs that present late, even if they are young. The available nerve transfers should be utilized for innervation of free functioning muscles. On the other hand, we can continue to have an optimistic outlook for C56 palsies even at delays as long as 18-19 months.

Nerve transfers which have worked for me

Nerve transfers which have worked for me

Lyme neuroborreliosis: a treatable cause of acute ocular motor disturbances in children

BackgroundLyme neuroborreliosis (LNB) designates central nervous system involvement caused by the tick-borne spirochaete Borrelia burgdorferi (Bb). The present study describes a spectrum of acquired ocular motor disorders in children with...

5:36 PM, Abstract No. 320 - Head and neck endovascular repair of vascular malformations

To determine the efficacy of ethanol embolotherapy of extracranial head and neck vascular malformations of all types, particularly after failure of other endovascular and surgical treatments. One hundred and sixty-six patients (64 males, 102 females; mean age: 38 yrs) presented with extracranial arteriovenous malformations (AVMs) of the head and neck area. Over half of the patients had undergone previous failed therapies. All patients underwent ethanol embolotherapy under general anesthesia. Forty-five patients had AVMs and 121 patients had venous malformations (VM). Of 45 AVM patients, 26 patients are cured (mean follow-up 2 ½ years); of 121 venous malformation patients, 65 are at end-therapy (mean follow-up 4 ½ years). The remaining patients are not at end-therapy and are being treated for their residual malformations. In AVM follow-up, arteriography is the main imaging modality to determine cure or residual AVM as MR is less sensitive in the evaluation of residual AVM. In VM follow-up, MR is the main imaging tool, particularly with T- 2 fat suppression and/or STIR imaging. All patients demonstrated improvement post-therapy. Complications were 4.5%, to include bleeding (self-limited), partial 7th nerve palsy (with recovery), skin injury (not requiring skin grafts), infection, and pain. Ethanol has proven its consistent curative potential at long-term follow-up for high-flow AVMs and low-flow VM lesions at long-term follow-up as lesions in the periphery. Complication rates remain low. The procedures are tolerated well by the patients and done on an outpatient basis. Prior surgery and embolization procedures can cause difficulty in lesion access, but does not obviate further ethanol endovascular treatment.