cranial nerve palsies

Slide 1 :Ocular Motor Nerve Palsies Dr. Kiruba E Paul, D.O, DNB, FRCS (Glasg)‏ Consultant - Neuro-Ophthalmology Services Aravind Eye Hospital Coimbatore


Slide 2 :Evaluation - clinical approach Isolated Multiple Recurrent


Slide 3 :Ocular Motor Nerve Palsies History Onset & duration of double vision Recent Trauma? Recent Illness? Personal Medical History Diurnal variations? Pain, Redness, Swelling


Slide 4 :Isolated Third Nerve Palsies Vascular Demyelination Traumatic Aneurysm Tumor Congenital Idiopathic


Slide 5 :Isolated Third Nerve Palsies R/o fourth nerve palsy Is the pupil involved or spared ? Is the palsy complete or incomplete ? Any signs of aberrant regeneration?


Slide 6 :Why is Pupil so important ? Location of Pupillary Fibres


Slide 7 :Why is Pupil so important ? Third Nerve in relation to PCA Pupil is ALMOST ALWAYS involved in third nerve palsies due to aneurysms


Slide 8 :Isolated Third NPs – Pupil Involved First rule-out an aneurysm WHY ? Results of treatment of unruptured PCA Aneurysms are good in 75% and fair in 25% with < 0.5% mortality


Slide 9 :Isolated Third NPs – Pupil Involved 12% - 45% of pts who experience rupture of an IC aneurysm die immediately Chances of remaining alive 10 years after rupture are 20% Surgical mortality 1% - 5%


Slide 10 :Isolated Third NPs – Pupil Involved Hence we need to pick-up Aneurysmal Third NPs early ! Non-invasive imaging is a must MRI MRA / CTA Digital Subtraction Angiography (If MRA is suspicious)‏


Slide 11 :Isolated Third NPs – Pupil Involved Aneurysms causing Third NPs are always more than 3 - 5mm MRA & CTA have high sensitivity for aneurysms more than 3mm


Slide 12 :Isolated Third NPs – Pupil Involved Other causes Tumour Traumatic Congenital Rarely Ischaemia, HZ


Slide 13 :Isolated Third NPs – Pupils Spared Complete / Incomplete If Incomplete Evaluate as if pupil were involved If complete Not an Aneurysm Vascular Etiology Post Viral


Slide 14 :Aberrant Regeneration Elevation of UL with depression or adduction Causes Trauma Tumour Aneurysm Congenital Neuro-imaging if it is not traumatic


Slide 15 :Fourth Nerve Palsies Traumatic Vascular Congenital Aneurysm Tumor Demyelination Unknown


Slide 16 :Isolated Fourth NPs H/O trauma….Look for B/L palsy No H/O trauma….R/o congenital palsy


Slide 17 :Isolated Fourth NPs Consider nature of onset Assess degree of torsion Vertical Fusion range Check old Photograph


Slide 18 :Isolated Fourth NPs Congenital (not previously diagnosed)‏ Head tilt in old photographs vertical fusion amplitude >3 prism diopters [10-15]


Slide 19 :Isolated Fourth NPs When Traumatic consider possibility of masked bilateral palsies - 30% Spontaneous complaint of double vision with torsion Alternating hyper (i.e.. R HT in left gaze & L HT in right gaze)‏ V-pattern esotropia >10º of torsion with double maddox rods Often need surgical correction


Slide 20 :Isolated Fourth NPs Close observation / MRI Brain if No definite history of trauma Insidious onset No vascular risk factors


Slide 21 :Sixth Nerve Palsies Vascular Tumor Demyelination Traumatic Aneurysm Infectious / Unknown


Slide 22 :Sixth Nerve Palsies Careful optic disc evaluation


Slide 23 :Sixth Nerve Palsies 21 yrs/M B/L sixth nerve palsy Disc edema Frontoparietal SDH ITP


Slide 24 :Sixth Nerve Palsies Look for PF changes Duanne’s Retraction Syndrome


Slide 25 :Sixth Nerve Palsies Consider each case as abduction weakness & r/o TRO OID Orbital Trauma with MR entrapment MG


Slide 26 :Sixth Nerve Palsies Examine for Proptosis, lid retraction & Lid lag (TRO)‏ USG & TFT Painful Proptosis (OID)‏ H/o trauma with +ve FDT Look for Mild ptosis & lid twitch (MG)‏ Fatigue test / Neostigmine test


Slide 27 :Sixth Nerve Palsies Whether or not the Palsy is truly isolated Count 2 to 12 and assess the cranial ns Look for Horner’s Syndrome (CS, BS lesions)‏


Slide 28 :Sixth Nerve Palsies 44 years female Right 6th N palsy with early 3rd & 5th nerve paresis Right trigeminal Schwannoma


Slide 29 :Sixth Nerve Palsies 25 years male Left 6th nerve paresis & Orbicularis Weakness Pontine haemorrhage ? Vascular malformation in dorsal pons


Slide 30 :Sixth Nerve Palsies 55 years old female Left 6th Nerve palsy & Lt sensory neural deafness Left CP angle mass - Acoustic Schwannoma


Slide 31 :Sixth Nerve Palsies 25 yrs / male RLR palsy & 12 N paresis Painful Neck movements Nasal tone MRI-mass in skull base Biopsy –nasopharyngeal carcinoma


Slide 32 :Isolated Sixth NPs Age of the patient Nature of onset Progression Vascular risk factors


Slide 33 :Isolated Sixth NPs Patient > 40 years with Vasculopathic history Acute onset Non-progressive Consider medical examination, FBS, lipid profile, ESR Follow at 4 week intervals for 3 months before diagnostic testing


Slide 34 :Isolated Sixth NPs Pts >40 years without vasculopathic history Insidious onset & Progressive ± vasculopathic history Evaluation mandatory MRI ENT examination


Slide 35 :Isolated Sixth NPs 45 years old male RLR palsy-1month,progressive No vascular risk factors Clivus chordoma


Slide 36 :Isolated Sixth NPs Patients < 40 years No vasculopathic history Consider CBC, ESR, TPHA, FBS, CXR Neuro-imaging is a must if No sign of resolution by 3 to 4 weeks If persistent severe pain Progressive with additional neurologic sign


Slide 37 :Isolated Sixth NPs 34 year male RLR palsy – 2mths Rt Temporal lobe lesion adjacent to cavernous sinus with meningeal enhancement-inflammatory


Slide 38 :Isolated Sixth NPs If non resolving and no cause found , re-evaluate for MG EOM restrictions disrespect boundaries of cranial ns Normal pupil Orbicularis weakness


Slide 39 :Management In adults Treat underlying disorder Patch involved eye Press-on-prism for small deviations Strabismus Sx for large stable deviations >30 PD In children (<11 years)‏ Avoid Patching Risk of amblyopia in deviated eye Press-on-Prisms if stable


Slide 40 :Multiple OMNPs SOF lesions Orbital apex lesions Cavernous sinus lesions Diffuse lesions of skull base Brain stem lesions


Slide 41 :Multiple OMNPs 45 yrs / female Defective vision RE-4days - with proptosis, third & sixth nerves palsies Right orbital apex syndrome Right posterior ethmoidal mucocele


Slide 42 :CAVERNOUS SINUS LESIONS Inflammatory Infective [Cs thrombosis] Infiltrative Primary Secondaries Local distant Aneurysm AV fistula


Slide 43 :CAVERNOUS SINUS LESIONS Carefully check for Proptosis / chemosis / bruit Mild ptosis & miosis Intorsion Dilated pupil Facial & corneal sensation All cranial ns of both the sides


Slide 44 :CAVERNOUS SINUS LESIONS 41 yrs/F Left Third, fourth, fifth,& sixth nerve palsies - 6 months Dilated pupil Left cavernous sinus meningioma


Slide 45 :Recurrent Nerve Palsies Uncontrolled Diabetes Multiple Sclerosis Migrainous MG Connective Tissue Disorder Recurrence of tumors


Slide 46 :Recurrent Nerve Palsies 32 year male LLR palsy-1week H/o previous similar episode – 3yrs back H/o surgery in the neck Left glomus jugulare tumour


Slide 47 :Take Away Synopsis


Slide 48 :3rd NPs – Pupil involvement / Evolving -> First rule out Aneurysm 4th NPs – Rule out congenital form 6th NPs – First establish if it is isolated


Slide 49 :Multiple OMNPS – Be Careful not to miss CS Thrombosis / Nasopharyngeal Ca / Fungal Pansinusitis Recurrent NPs – Keep your ? alive till you find out why??


Slide 50 :Thank You