Trochlear Nerve Research Articles

Two Cases Report of Acupuncture Treatment at the Acupoint BL1 (Jingming) of Both Eyes in Treating Traumatic Trochlear Nerve Palsy

Purpose: To explore a safe and effective therapy in treating diplopia due to traumatic trochlear nerve palsy. Subjects: Two cases of traumatic trochlear nerve palsy both induced by motorcycle traffic accidents were presented in this study. Both cases were right superior oblique muscle palsy after an accidental head injury affected for more than 6 months (case 1) and 4 years (case 2). Methods of treatment: Both cases were subjected to acupuncture therapy at the acupoint BL1 (Jingming) of both eyes using disposable stainless steel acupuncture needles and were clinically evaluated by the ophthalmologist after each session. Each session extended to 20 minutes, 2 or 3 sessions per week till fully recovered. Result: Clinical symptoms of both cases were significantly improved after 3 sessions and continued the treatment for two more months to consolidate the curative effect due to fear of recurrence of symptoms. Conclusion: Acupuncture can be considered an effective therapy in the treatment of diplopia due to traumatic trochlear nerve palsy in addition to conservative therapy.

High-Resolution 7T MR Imaging of the Trochlear Nerve.

The trochlear nerve has traditionally been difficult to identify on MR imaging. The advent of 7T MR imaging promises to greatly benefit visualization of small structures due to gains in the signal-to-noise ratio allowing improved spatial resolution. We investigated the utility of a clinically feasible ultra-high-resolution 7T MR imaging protocol for identification of the trochlear nerve, as well as assessment of normal trochlear nerve anatomy. Coronal high-resolution 2D T2-weighted TSE images used in a 7T epilepsy protocol of 50 subjects at our institution were reviewed by 2 independent radiologists for visualization of the trochlear nerve at the nerve origin and cisternal, tentorial, and cavernous segments. The frequency of nerve visibility within these segments and their anatomy were documented, and disagreements were resolved by joint review. Of the 100 nerves reviewed in 50 subjects, at least 2 segments of the trochlear nerve from the brainstem to the cavernous sinus were identified in 100% of cases. The origins from the brainstem and cisternal segment were visible in 65% and 93% of nerves, respectively. The trochlear nerve was identified at the trochlear groove in 100% of cases and in the posterior wall of the cavernous sinus in 74% of cases. Coronal high-resolution 2D TSE at 7T reliably identified the trochlear nerve throughout its course and is a promising tool for imaging patients with suspected trochlear nerve pathology.

Trigeminal nerve sheath tumor presenting as trochlear nerve palsy

A 73-year-old woman presented with vertical diplopia which was diagnosed as a trigeminal nerve sheath tumor. This case was unusual because the principal symptom was a vertical diplopia due to involvement of the trochlear nerve. Trigeminal function was preserved on initial presentation. The patient was advised neuroimaging along with baseline blood investigations. On subsequent follow-ups she developed trigeminal symptoms in the form of tingling and numbness along her left cheek and below her left eye. Eventually, radiodiagnosis showed a dumbbell-shaped necrotic lesion originating from the trigeminal nerve sheath suggestive of a schwannoma. The case was then referred to a neurosurgeon for appropriate management.

Neurovascular Structures at Risk During Surgical Access to Trigeminal Ganglion and Meckel's Cave - An Anatomical Study.

It is difficult to approach the Trigeminal Ganglion (TG) and Meckel's cave (MC) during surgeries. Therefore, the exact knowledge of the relationship of surgical landmarks to related anatomical structures is vital to reduce the associated postoperative morbidity. The aim of the present study was to enhance the knowledge of the surgical anatomy of structures that are present in the conduit of all surgical approaches to TG and MC, their distances from surrounding neurovascular structures, and their variations. The study was carried out on 40 embalmed cadavers (Eight Female) of the anatomy department of a teaching hospital in Central India. Meticulous dissection of cranial fossae was done to locate TG, MC, and related anatomical structures. All distances from TG and MC were measured using an electronic digital calliper. Length, width, and thickness of TG were 15.39 mm, 4.39 mm, and 2.54 mm, respectively. The distance from zygomatic arch, the lateral end of the petrous ridge, arcuate eminence, foramen ovale, and foramen spinosum to MC was 26.10 mm and 37.94 mm, 16.46 mm, 4.54 mm, and 11.23 mm, respectively. The sixth, fourth, and third cranial nerves were 6.26 mm, 4.94 mm, and 2.53 mm from MC, respectively. The MC was 42.72 mm and 33.87 mm anteromedial from posterior and anterior limits of the sigmoid sinus. Findings of the present study will aid surgical planning and decide the approach to TG and MC and avoid surgical complications.

Bilateral third and fourth cranial nerve palsy presenting secondary to central nervous system tuberculoma

Central nervous system (CNS) tuberculoma can have variable presentations depending on the site and number of tuberculomas. We report a rare case of a 48-year-old male presenting with ptosis and binocular double vision. Clinical examination revealed bilateral third-nerve palsy and fourth-nerve palsy with nystagmus. Magnetic resonance imaging (MRI) of the brain revealed ring-enhancing lesion in the dorsal midbrain, suggestive of tuberculoma. Radiological search for tuberculous foci in other internal organs proved pulmonary tuberculosis. Mantoux was positive, confirming the exposure to tuberculous bacilli. He was started on low-dose steroids along with antitubercular therapy (ATT). There was no improvement after continuing ATT for one-and-a-half years. Thus, the prognosis of CNS tuberculoma is related to the timing of initiating appropriate therapy. Delays in diagnosis and treatment will result in poor prognoses and severe neurological sequelae.

Congenital isolated unilateral third nerve palsy in children: the diagnostic contribution of high-resolution MR imaging.

To describe the neuroanatomical correlates of unilateral congenital isolated oculomotor palsy by means of high-resolution MRI. Children with a clinical diagnosis of congenital isolated oculomotr palsy and with a high-resolution MRI acquisition targeted on the orbits and cranial nerves were selected and included in the study. An experienced pediatric neuroradiologist evaluated all the exams, assessing the integrity and morphology of extraocular muscles, oculomotor, trochlear and abducens nerves as well as optic nerves and globes. Clinical data and ophthalmologic evaluations were also collected. Six children (age range: 1-16 years; males: 3) were selected. All patients showed, on the affected side (left:right = 5:1), anomalies of the III nerve and extraocular muscles innervated by the pathological nerve. One patient had complete nerve agenesis, two patients showed a diffuse thinning of the nerve, from the brainstem to the orbit and 3 patients showed a distal thinning of the oculomotor nerve, starting at the level of the cavernous sinus. In all cases atrophy of corresponding muscles was noticed, but the involvement of the affected muscles varied with the nervous pattern of injury. High-resolution MRI represents a valuable tool for the diagnosis of III nerve anomalies in unilateral congenital IOP, showing different patterns of nerve involvement and muscular atrophy.

Clinicoradiological profile and outcome of cavernous sinus syndrome with coronavirus disease-2019-associated rhino-orbito-cerebral mucormycosis.

With coronavirus disease 2019 (COVID-19) pandemic across the world, there had been an exponential increase in rhino-orbito-cerebral mucormycosis (ROCM). Extension of infection to cavernous sinus leads to cavernous sinus syndrome (CSS). This study aims to describe incidence, clinicoradiological profile, and outcome of CSS positive along with comparative analysis of CSS negative COVID-19-associated ROCM. This was a prospective and observational study conducted from May 1, 2021, to July 31, 2021. Subjects included ROCM with active or recovered COVID-19 (past 6 weeks) and were categorized and staged. CSS was defined as involvement of two or more of third, fourth, fifth, or sixth cranial nerve with one each direct and indirect qualitative neuroradiological features. Clinicoradiological features of CSS-positive and negative COVID-19-associated ROCM groups were compared. Incidence of CSS with COVID-19-associated ROCM was 28%. Mean age of subjects was 44 ± 15 years with 60% being males and 73% were proven ROCM. Significant differences seen across the CSS-positive and negative groups were ocular, nasal, and cerebral findings including eyelid and periocular discoloration, ptosis, proptosis, ophthalmoplegia, nasal discharge, mucosal inflammation, and fever. Oculomotor, trochlear, and abducens nerves were significantly involved more in CSS-positive group. Significant radiological findings across two groups included indirect features in orbit, nose, and paranasal sinuses along with direct features in cavernous sinus. Surgical intervention was more common in CSS-positive group. Mortality in CSS-positive group at 8-24 weeks was 13 and 27%, respectively. Extension of ROCM to CSS was more common in young males in advanced stages of proven ROCM with concurrent COVID-19. CSS-positive group had significant difference in clinicoradiological features involving orbit, nose, paranasal sinuses, and central nervous system as compared to CSS-negative group. This study highlights the need to develop an objective scoring system considering clinical and radiological features for diagnosis of CSS with COVID-19-associated ROCM.

Oculomotor and trochlear nerve neuritis following botulinum toxin injection for masseter hypertrophy - a case report with literature review.

To report a rare complication of oculomotor and trochlear nerve neuritis following botulinum toxin injection for masseter hypertrophy. A previously healthy 31-year-old man presented with a two-week history of left eye (OS) ptosis and diplopia, following botulinum toxin injection over the masseter area for masseter hypertrophy at an aesthetic centre. He had no proptosis or facial asymmetry. Visual acuity was 6/6 in the right eye (OD) and 6/9 in the OS. There was anisocoria, with pupils measuring 3 mm in the OD and 5 mm in the OS but no relative afferent pupillary defect. OS appeared hypertropic in primary gaze with impaired intorsion. Extraocular movement of the OS was restricted in all gazes, except for laevoversion; that of the OD was normal. This was associated with diplopia in all gazes except on laevoversion. Both eyes' anterior and posterior segment examinations were otherwise unremarkable. Besides the oculomotor and trochlear nerve, the other cranial nerves and neurological examinations were normal. Investigations including blood and cerebrospinal fluid, magnetic resonance imaging and angiography of the brain, were normal. Our impression was left oculomotor and trochlear nerve neuritis secondary to botulinum toxin injection. He was started on oral prednisolone 1 mg/kg daily and tapered by 5 mg per week. His condition improved gradually with no residual ptosis or anisocoria after three months. Extraocular movements normalised except for minimal residual restriction on depression. Oculomotor and trochlear nerve neuritis can occur following botulinum toxin injection over the masseter area. Healthcare professionals should be aware of this potential complication before offering the injection.

Development and 5-year Evaluation of Diagnosis-Specific Protocols for Visual Neuro-Rehabilitation in a Multicenter Inpatient Rehabilitation Network

ObjectiveTo provide a retrospective evaluation of a new eye and vision rehabilitation care pathway in a U.S. multi-site inpatient rehabilitation network involving the occupational therapy (OT) staff and a consulting doctor of optometry (OD) specializing in vision rehabilitation. DesignRetrospective study. SettingTwo Inpatient Rehabilitation Facilities (IRFs) and 1 Long Term Acute Care Hospital (LTACH). ParticipantsThere were 2083 records reviewed (44% women, avg. age 59 years). The most common diagnoses were hemispatial neglect (19.2%), homonymous field defects (18.5%), and oculomotor cranial nerve palsies (16.7%) (N=2083). InterventionsClinical care was reviewed where diagnosis-specific protocols were developed and training was provided to OTs in order to reinforce OD-prescribed interventions during daily treatment sessions, including (1) third, fourth, and sixth ocular cranial nerve palsies (OCNPs) with prisms fitted for full time, postural adaptation training, and oculomotor re-education using pursuits, saccades, head-rotations, and binocular vision exercises including alternate cover and vergence; (2) homonymous hemianopia with training awareness of field loss, eccentric viewing, and fitting of Peli lens for optical field expansion; and (3) prism adaptation therapy (PAT) for left hemispatial neglect. Main Outcome MeasuresFrequency of diagnoses. HypothesisDiagnoses with developed protocols were most common. Secondarily, feasibility and efficacy by anonymous OT survey. Results2083 vision consults were performed over 5 years. The most common diagnoses were hemispatial neglect (n=399, 19.2%), homonymous field defects (n=386, 18.5%), and OCNPs (n=347, 16.7%). None of the OTs reported the protocols were infeasible and 63% (IQR 38%-69%) reported their patients benefited from the interventions. The survey suggested prism for OCNPs helped in 42%, and Peli lens and PAT both helped in 38%. ConclusionsData support the feasibility of this inpatient eye and vision rehabilitation care pathway which may be used as a foundation for creating or refining similar programs elsewhere. Uniform administration of IRF-based visual neuro-rehabilitation care could provide a substrate for future clinical trials to evaluate efficacy.

Serum Calcitonin Gene-Related Peptide Is Elevated in Patients With Migraine and Ophthalmoplegia.

There is ongoing debate about whether the oculomotor (III), trochlear (IV), or abducens (VI) nerve paresis in patients with migraine is directly attributable to migraine (ophthalmoplegic migraine [OM]) or is due to an inflammatory neuropathy (recurrent painful ophthalmoplegic neuropathy [RPON]). As migraine is associated with elevated serum calcitonin gene-related peptide (CGRP) levels, we studied serum CGRP levels among patients with OM/RPON to determine whether they are elevated during and between attacks. This is the first study assessing CGRP levels in the serum of patients with OM/RPON. The aim of this case-control study was to assess serum CGRP levels in patients with ophthalmoplegia and a headache consistent with migraine according to ICHD-3 criteria. Serum CGRP levels were measured during the ictal and interictal phases in 15 patients with OM/RPON and compared with age-matched and sex-matched controls without migraine (12 patients). The median serum CGRP levels were significantly elevated ( P = 0.021) during the ictal phase (37.2 [36.4, 43.6] ng/L) compared with controls (32.5 [30.1, 37.3] ng/L). Serum CGRP levels during the attack correlated with the total duration of ophthalmoplegia. A CGRP level of 35.5 ng/L in the ictal phase of the attack had a sensitivity of 86.7% and specificity of 75.0% in diagnosing a patient with OM/RPON. Elevated serum CGRP levels during the ictal phase of OM/RPON favor migraine as the underlying cause of episodic headache with ophthalmoplegia.

Аномальное положение головы: новая парадигма

Purpose. To determine the most common ocular causes and types of anomalous head position and give details of their functional features. Material and methods. The research included 105 patients with an anomalous head position. Depending on the oculomotor pathology, patients were divided into 6 groups. 1st group – 10 patients with Brown syndrome, 2nd group – 20 patients with Duane syndrome of types 1 and 2, 3rd group – 30 patients with nystagmus, 4th group – 30 patients with n. abducensparalysis, 5th group – 15 patients with n. trochlearisparalysis, and control 6th group – 20 patients with one of the above pathology, but without anomalous head posture (AHP). Results. Out of 105 patients with AHP, 83.8% had both fusion and stereopsis. There was no statistical difference in the rate of fusion or stereopsis among the different AHP types (p=0.580). The control group showed accurately low scores of stereopsis and fusion loss (5.3%) (p=0.001). The overall incidence of amblyopia in all groups of patients with AHP (with Brown, Duyane syndrome, with nystagmus by 3.7 times, with paralysis and paresis of n. abducensand n. trochlearis) is statistically significantly lower (p<0.001) than in the control group. Conclusion. The most common ocular causes of anomalous head position are nystagmus and paralysis of the abducens nerve, as well as Duane syndrome and paralysis of the trochlear nerve. Head rotation is most commonly associated with congenital nystagmus, Duane syndrome, and n. abducens paralysis and paresis. Head tilt or various combinations of head tilt with a raised chin is most characteristic of n. trochlearis paralysis and paresis and Brown syndrome. AHP formation is a «protective» mechanism in terms of developing amblyopia and loss of binocular single vision. Key words: abnormal head position, binocular vision, stereopsis, amblyopia.

Clinical Characteristics of Acquired Diplopia in Adults

ABSTRACT Purpose To describe the common causes of symptomatic strabismus and treatment required to resolve diplopia in adult patients seen by one orthoptist. Patients and Methods Retrospective cross-sectional study of consecutive adult patients 18 years or older seen by one orthoptist over a 3-year period with a chief complaint of double vision. Results Two hundred twenty-four consecutive adult patients were examined by the author. Chief complaint was double vision, followed by blurred vision, monocular diplopia, and eye strain. Past ocular histories were significant for early-childhood strabismus in 23 patients. Amblyopia was identified in five patients. Hypertension was a medical risk factor most associated with symptomatic strabismus. Cranial nerve paresis was the most common cause of the strabismus followed by benign, age-related divergence insufficiency esotropia. Prism was the most common treatment in 53% of patients followed by Bangerter foil occlusion in 44 patients (20%). Strabismus surgery was recommended in 11 patients (5%). Manifest refraction was successful in resolving symptoms of binocular diplopia in nine heterophoric patients (5%). Opaque pirate style occlusion was not used for any patient in this series. Conclusions Symptomatic acquired esotropia was a common type of strabismus encountered by the author and trochlear nerve paresis a common cause of symptomatic strabismus in this retrospective cross-sectional study. Press-On™ or ground-in spectacle prism of 12 prism diopters or less resolved diplopia in 124 patients (55%).

Tentorial peeling during combined petrosal approach: a cadaveric dissection.

The combined petrosal approach is an excellent method to access the petroclival region but has the inherent risk of injury to the temporal lobe and Vein of Labbé. Tentorial peeling has the potential to largely eliminate these risks during the classic combined transpetrosal approach. Anatomical dissection of three adult injected non-formalin fixed cadaveric heads was performed. Combined petrosal approach with tentorial peeling was completed. A tentorial incision just superior and parallel to the superior petrosal sinus was made to enable peeling of the tentorium into two layers, the posterior fossa tentorial leaf (PFTL), and the temporal tentorial leaf (TTL). Tentorial peeling clearly exposed the continuity betweenthe temporal dura and the TTL as well as the continuity betweenthe presigmoid dura and the PFTL.This enabled the creation of a large dural flap extending to the tentorial incisura, providing wide access to the petroclival region without any exposure of the temporal lobe and/or basal temporal veins.Techniques to create the dural flap without trochlear nerve injury were also explored. The technique of tentorial peeling into two distinct layers has the potential to reduce the morbidity associated with temporal lobe retraction and venous injury. Further cadaveric studies and surgical case series are needed to validate this important surgical nuance in transpetrosal approaches.

A rare presentation of neurosarcoidosis as the superior orbital fissure syndrome

We are reporting a rare case of neurosarcoidosis that presented with superior orbital fissure syndrome. A 51-year-old Indian woman who suffered from 2 weeks duration, insidious onset gradually progressive left sided headache limited to forehead, left periorbital pain, diplopia on looking toward left, and numbness on the left forehead was referred to our hospital. Ophthalmic findings included left oculomotor nerve, trochlear nerve and abducens nerve palsies, absent corneal reflex, and loss of touch, pain and temperature sensation in V1 distribution. Brain and orbit magnetic resonance imaging (MRI) showed contrast enhancing area at the left orbital apex with normal optic nerve. Normal CSF analysis. High ESR, and chest x-ray showing non-homogenous patchy opacities in bilateral lung fields leaded us for neoplastic screening. Chest computed tomography (CT) revealed multiple ill-defined irregular lung parenchymal nodular opacities of varying sizes involving bilateral lungs with enlarged mediastinal and bilateral axillary lymph nodes. Elevated angiotensin converting enzyme level was found. Biopsy of the axillary lymph node showed non-caseating granulomatous lymphadenitis with giant cells containing schaumann bodies and asteroid bodies in the cytoplasm. These findings indicating an inflammatory response induced by sarcoidosis. After the initiation of steroid treatment, the patient experienced complete remission without any recurrence. When examining a case presenting with superior orbital fissure syndrome with contrast enhancing MRI lesion at the orbital apex, the additional chest CT to exclude neoplastic lesions can detect pulmonary sarcoidosis and extraneural lesions. These may avoid delays in the diagnosis and management of neurosarcoidosis.

Studying the structure of the nucleus of the trochlear nerve in mice through 7 days of readaptation to earth gravity after spaceflight

The negative effect of hypogravity on the human organism is manifested to a greater extent after the astronauts return to the conditions of habitual gravity. In this work, to elucidate the causes underlying atypical nystagmus, arising after the flight, we studied structural changes in the motoneurons of the trochlear nerve after a 7-day readaptation of mice to the conditions of Earth's gravity. It is known, that motoneurons of the trochlear nerve innervate the muscle that controls the movement of the eyes in the vertical direction. We showed that the number of axodendritic synapses and some other morphological parameters of motoneurons changed by microgravity can return to their original state in 7 days. However, according to some parameters, motoneurons retain a “memory” of the action of microgravity and do not completely restore the structure. The volume of the soma, the shape of the nuclei, the number and orientation of dendrites do not return to pre-flight parameters. The number of dendrites after 7 days of adaptation remained increased, and the proportion of dendrites in the ventrolateral direction became 2.5 times greater than in motoneurons after space flight. The increased number of mitochondria after space flight became even more significant after readaptation. Microgravity-induced plastic changes retain to some extent “memory traces” after readaptation to Earth's gravity. It can be assumed that the restoration of the function of the trochlear nuclei (overcoming nystagmus) is carried out not only by reversible restoration of the structure of neurons, but partially using those mechanisms that are formed in weightlessness.

Isolated Sudden-Onset Trochlear Nerve Palsy Associated with Mild Novel Coronavirus Disease (COVID-19) Infection

ABSTRACT Purpose To present a case of sudden isolated unilateral trochlear nerve palsy of new onset associated with a COVID-19 infection without a severe course. Methods A 49-year-old previously healthy man suddenly noticed seeing double while going down the stairs to go out for the first time the day after the completion of medical treatment and home isolation for COVID-19. There was no systemic disease or history of trauma. Results Magnetic resonance imaging of the brain and orbits was normal and the neurology examination revealed no pathology. The acute onset of the diplopia, the small vertical fusion amplitude, and the lack of facial asymmetry supported acquired trochlear nerve palsy. Conclusions Trochlear nerve palsy has rarely been reported in association with the various types of viral infections. To the best of our knowledge, this is the first case of isolated unilateral trochlear nerve palsy with no additional neurological finding or any radiological finding that is possibly associated with mild SARS-CoV-2 infection.

Microsurgical Anatomy of the Cerebellar Interpeduncular Entry Zones

The cerebellar interpeduncular region, particularly the middle cerebellar peduncle (MCP) and interpeduncular sulcus (IPS) are significant surgical relevance areas due to the high prevalence of vascular and tumoral pathologies, such as cavernomas, arteriovenous malformations, and gliomas. We defined safer access areas of the MCP and the IPS, according to the surface anatomy, involved vessels, and fiber tracts of the cerebellar interpeduncular region. Fifteen formalin-fixed and silicone-injected cadaveric heads and 23 human brainstems with attached cerebellums prepared with the Klingler's technique were bilaterally dissected to study the vascular and intrinsic anatomy. Surface anatomy: The mean length of the IPS was 12.73mm (standard deviation [SD],2.15mm), and the average measured angle formed by the IPS and the lateral mesencephalic sulcus was 144.53°. The mean distance from the uppermost point of the IPS to cranial nerve IV was 2.63mm (SD, 2.84mm). Vascular anatomy: The perforating branches of the superior cerebellar peduncle, IPS, and MCP originated predominantly from the caudal trunk of the superior cerebellar artery. The inferior third of the superior cerebellar peduncle and IPS was the third most pierced by perforating arteries, and for the MCP, was its superior third. Crossing vessels: The branches of the pontotrigeminal vein and the caudal trunk of the superior cerebellar artery crossed the IPS mostly. The superior third of the IPS was the most crossed by arteries and veins. The middle thirds of the IPS and MCP as entry zones might be safer than their superior and inferior thirds due to fewer perforating branches, arterial trunks, and veins crossing the sulcus as fewer eloquent tracts.

Partial Transvenous Coil Embolization with Significant Clinical Improvement in Patient with Indirect Carotid Cavernous Fistula

Highlight: CCF is a rare vascular malformation with challenging management. Partial transvenous embolization is quite effective as an alternative therapy for indirect CCF type D. ABSTRACT Introduction: An indirect carotid-cavernous fistula (CCF) is an abnormal connection between the internal or external carotid artery and the cavernous sinus. The optic, trochlear, abducens, and trigeminal nerves are located in the cavernous sinus. Head Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI), and Cerebral Angiography are some imaging modalities used to establish and diagnose carotid-cavernous fistula. Endovascular intervention can be performed with trans-arterial or trans-venous access. In some cases, complete embolization by endovascular treatment is not possible because of difficult angioarchitecture. Case: A 61-year-old female reported having pain in her left eye (numerical rating scale was 6). The left eye was bulging, reddish, ptosis, and unable to move. The patient felt double vision when opening both eyes, complained of intermittent stabbing headaches on the left side, and heard a bruit from the left side of the head. The cerebral angiography showed bilateral indirect CCF Barrow type D. The procedure involved partial transvenous embolization with coiling. The angiographic evaluation showed partial occlusion, and residual flow from the fistula was still visible on angiography. There was a significant clinical improvement several days after the procedure and a five-month follow-up. Conclusion: This case report showed that partial targeted transvenous embolization is quite effective in indirect CCF when complete embolization is impossible.

Recurrent Painful Ophthalmoplegic Neuropathy with Unilateral Oculomotor and Trochlear Nerve Palsy in an 8-year-old Girl

ABSTRACT Background Recurrent painful ophthalmoplegic neuropathy (RPON) is a rare disorder with a unilateral headache accompanied by ipsilateral episodes of painful ocular cranial nerve neuropathy, which typically occurs in childhood. Case report We report an 8-year-old female with four episodes of RPON involving unilateral third and fourth cranial nerves. Right eye exotropia and complete ptosis were detected on examination. Brain MRI images revealed right third nerve enhancement where it exits from the brainstem. She completely recovered after 5 weeks with the administration of prednisolone and indomethacin. Discussion and conclusion Due to the rarity of this condition in children, recurrent painful ophthalmoplegic neuropathy should be considered as a differential diagnosis of unilateral or bilateral painful ophthalmoplegia, particularly with a history of migrainous headache. Since it is a treatable entity, and repeated attacks may lead to permanent sequela, early intervention is crucial.

A Case with Bilateral Dural Arteriovenous Fistulae Manifesting as Sequential Trochlear, Oculomotor Nerve Palsies

Purpose: We report a patient with bilateral dural arteriovenous fistulae (DAVF) who initially presented with unilateral, isolated trochlear nerve palsy; and later with contralateral, oculomotor nerve palsy.Case summary: A 72-year-old male without any underlying disease or a trauma history visited with sudden vertical diplopia in both eyes that had developed 5 days prior. Brain magnetic resonance imaging (MRI) performed before his first visit was unremarkable. The eye movement test revealed hyperdeviation and limitation of downgaze in the left eye; we thus suspected unilateral, ischemic trochlear nerve palsy and this was indeed observed. However, the diplopia did not improve and limitations of the upper, medial gaze of the right eye developed after 3 months. Follow-up examinations (orbital computed tomography, brain MRI, and cerebral angiography) revealed bilateral DAVF running from the left to the right. He underwent gamma-knife radiosurgery; then the eye movement limitations and diplopia improved.Conclusions: Diplopia manifesting as paralysis in an elderly patient may be caused by DAVF; the diplopia may not always be the common ischemic paralytic strabismus. DAVF should be considered during differential diagnosis and further radiological examinations may be needed.