Delayed Trochlear Nerve Palsy Following Traumatic Subarachnoid Hemorrhage: Usefulness of High-Resolution Three Dimensional Magnetic Resonance Imaging and Unusual Course of the Nerve

Young San Ko,Hee-Jin Yang,Young-Je Son,Sung Bae Park,이상형,정영섭 대한신경손상학회 2018 Korean Journal of Neurotrauma Vol.14 No.2

Cranial nerve palsies are relatively common after trauma, but trochlear nerve palsy is relatively uncommon. Although traumatic trochlear nerve palsy is easy to diagnose clinically because of extraocular movement disturbances, radiologic evaluations of this condition are diffcult to perform because of the nerve’s small size. Here, we report the case of a patient withdelayed traumatic trochlear nerve palsy associated with a traumatic subarachnoid hemorrhage (SAH) and the related radiological fndings, as obtained with high-resolution three-dimensional (3D) magnetic resonance imaging (MRI). A 63-yearold woman was brought to the emergency room after a minor head trauma. Neurologic examinations did not reveal anyfocal neurologic defcits. Brain computed tomography showed a traumatic SAH at the left ambient cistern. The patientcomplained of vertical diplopia at 3 days post-trauma. Ophthalmologic evaluations revealed trochlear nerve palsy on theleft side. High-resolution 3D MRI, performed 20 days post-trauma, revealed continuity of the trochlear nerve and its abutted course by the posterior cerebral artery branch at the brain stem. Chemical irritation due to the SAH and the abuttingnerve course were considered causative factors. The trochlear nerve palsy completely resolved during follow-up. This caseshows the usefulness of high-resolution 3D MRI for evaluating trochlear nerve palsy

Diagnostic Utility of the Three-Step Test According to the Presence of the Trochlear Nerve in Superior Oblique Palsy

이지은,양희경,김재형,황정민 대한신경과학회 2018 Journal of Clinical Neurology Vol.14 No.1

Background and Purpose To determine the diagnostic utility of the three-step test in unilateral superior oblique palsy (SOP) according to the presence of the trochlear nerve using high-resolution thin-section magnetic resonance imaging. Methods In total, 166 patients with congenital and acquired unilateral SOP were included, comprising 87 with a normal trochlear nerve (present group) and 79 without a trochlear nerve (absent group). The sensitivity of each component of the three-step test was evaluated as well as factors related to the sensitivity. Results All three steps were positive in 78% of those in the present group and 72% of those in the absent group, demonstrating no intergroup difference (p=0.471). Superior rectus muscle (SR) contracture was more frequent in patients who exhibited at least one negative step (incomplete group) (p=0.014). The incomplete group was significantly related to larger hypertropia in ipsilateral gaze (p<0.001), smaller hypertropia in contralateral gaze (p<0.001), and smaller differences in hypertropia between ipsilateral head tilt and the primary position (p=0.012). Conclusions The diagnostic utility of the three-step test in unilateral SOP did not differ according to the presence of the trochlear nerve. SR contracture was the main cause of exceptions of the three-step test in unilateral SOP.

제2형 당뇨병 환자에서 발생한 자발적 안구마비 2예

김기훈,최지훈,계영하,장근영,김지웅,김태현,김경희,박병현,형근영,조정구 대한당뇨병학회 2000 임상당뇨병 Vol.1 No.1

Diabetics are predisposed to certain acute mononeuropathies, including a cranial neuropathy involving ocular motor nerves. Oculomotor nerve palsy is the most common cranial neuropathy in diabetes mellitus. Affection of several nerves in one eye can occur, rarely. Such as, the third and the sixth or the third and the fourth. The clinical characteristics of diabetes-associated ophathalmoplegia include abrupt onset, frequent occurrence of short-lived ipsilateral pain, sparing of pupillary reflex, resolution in most cases within a few months. Clinicopathological studies have suggested that diabetic ophathalomoplegia results from microvascular ischemia of an oculomotor nerve in its subarachnoid, cavernous segment or mid brain. Pupillary sparing is a single feature of diabetic third nerve palsy, and it has been widely used to distinguish diabetic oculomtor palsy from extrinsic compressive lesion of the third nerve, such as an aneurysm in the carotid siphon. No specific treatment is necessary. We experienced two cases of diabetic spontaneous ophthalmoplegia, one affected oculomotor nerve and the other affected partially oculomotor nerve and trochlear nerve, so we report these cases with review of the literatures.

해면정맥동 외측벽의 미세해부

정인혁,이혜연,강재규,이규성 대한신경외과학회 1993 Journal of Korean neurosurgical society Vol.22 No.7

In the microsurgical dissection of the lateral wall of the cavernous sinus. interrelationships of its nerves have been studied in 100 Korean adult half heads. And in the serial coronal section of the cavernous sinus in 10 half heads, the structures of the lateral wall have been studied. The relationships of the nerves of the lateral wall were classified to five types according to the course of the trochlear nerve. Each length of the Parkinson's triangle and the angle between trochlear and ophthalmic nerves were measured. These data were compared with those of the other races. The lateral wall of the sinus was composed of two layers. The orientation of the fibers of the deep layer was variable in regions. The oculomotor nerve was enveloped with sheath extended from dura mater and it was connected with deep layer of the lateral wall. The trochlear nerve was enveloped with sheath formed by division of innermost part of the deep layer. The venous sinus was found between the two layers of the lateral wall. The neurosurgical significance of the lateral wall of the sinus was discussed.

A Case of Herpes Zoster Ophthalmicus with Isolated Trochlear Nerve Involvement

박기정,윤성상,윤정은,이학영 대한신경과학회 2011 Journal of Clinical Neurology Vol.7 No.1

Background:Herpes zoster ophthalmicus (HZO) can involve the oculomotor nerve; however,isolated trochlear nerve palsy has rarely been reported. Case Report:An 83-year-old man who suffered from HZO in the right frontal area and scalp subsequently developed vertical diplopia and severe pain. Cerebrospinal fluid examination and brain MRI revealed no abnormalities. Isolated right trochlear nerve palsy was diagnosed based on the findings of neuro-ophthalmological tests. Conclusions:Isolated trochlear nerve involvement associated with HZO is very rare and may be easily overlooked. Physicians should carefully examine oculomotor involvement in HZO.

양안 복시로 나타난 도르래신경초종 1예

기현주(Hyun Ju Kee),류영주(Yung Ju Yoo),김재형(Jae Hyoung Kim),양희경(Hee Kyung Yang) 대한안과학회 2016 대한안과학회지 Vol.57 No.11

목적: 신경섬유종증이 없는 환자에서 단안의 도르래신경에 국한되어 발생한 신경초종 1예를 경험하였기에 이를 보고하고자 한다. 증례요약: 58세 남자가 10일 전부터 갑자기 발생한 복시를 주소로 내원하였다. 프리즘교대가림검사, 안구운동검사, 빌쇼스키머리기울임검사 소견이 좌측상사근마비에 부합하였다. 고해상도 뇌자기공명영상검사에서 좌측 도르래신경이 뇌간의 외측을 지나가는 위치에서 앞뒤 길이 6 mm 크기의 소엽모양의 종괴를 형성하였고, 얇은 절편 조영증강 자기공명영상을 추가로 시행하여 도르래신경초종을 확인하였다. 프리즘안경 착용을 통해 복시가 호전되어 추가적인 치료 없이 경과관찰하기로 하였다. 결론: 성인에서 후천상사근마비로 인해 발생한 복시의 경우 도르래신경종양을 감별해야 한다. <대한안과학회지 2016;57(11):1812-1816> Purpose: To report a case of unilateral trochlear nerve schwannoma in a patient without neurofibromatosis. Case summary: A 58-year-old male presented with acute onset of diplopia which developed 10 days prior. Alternate prism cover test, ductions and versions and Bielschowsky three-step test were compatible with left superior oblique muscle palsy. High-resolution magnetic resonance imaging showed a 6-mm-sized lobulated mass in the cisternal segment of the left trochlear nerve passing lateral to the brainstem. An additional thin-section gadolinium-enhanced orbit magnetic resonance imaging showed definite enhancement in the entire portion of the lobulated mass, compatible with a trochlear nerve schwannoma. Diplopia was managed conservatively with prism glasses and regular follow-up examinations were recommended without further treatment. Conclusions: A trochlear nerve tumor should be considered in adults who develop diplopia associated with acquired superior oblique muscle palsy. J Korean Ophthalmol Soc 2016;57(11):1812-1816

Isolated, Contralateral Trochlear Nerve Palsy Associated with a Ruptured Right Posterior Communicating Artery Aneurysm

Son, Seong,Park, Cheol-Wan,Yoo, Chan-Jong,Kim, Eun-Young,Kim, Jae-Myoung The Korean Neurosurgical Society 2010 Journal of Korean neurosurgical society Vol.47 No.5

Trochlear nerve palsy associated with spontaneous subarachnoid hemorrhage (SAH) is known to be a rare malady. We report here on a patient who suffered with left trochlear nerve palsy following rupture of a right posterior communicating artery aneurysm. A 56-year-woman visited our emergency department with stuporous mental change. Her Hunt-and-Hess grade was 3 and the Fisher grade was 4. Cerebral angiography revealed a ruptured aneurysm of the right posterior communicating artery. The aneurysm was clipped via a right pterional approach on the day of admission. The patient complained of diplopia when she gazed to the left side, and the ophthalmologist found limited left inferolateral side gazing due to left superior oblique muscle palsy on day 3. Elevated intracranial pressure, intraventricular hemorrhage or a dense clot in the basal cisterns might have caused this trochlear nerve palsy.

사구수조지방종에 의한 도르래신경마비 1예

최남현(Nam Hyeon Choi),김원제(Won Jae Kim),김명미(Myung Mi Kim) 대한안과학회 2018 대한안과학회지 Vol.59 No.11

목적: 중뇌(midbrain) 등쪽(dorsal)의 사구수조지방종(quadrigeminal cistern lipoma)에 의한 도르래신경마비를 경험하였기에 이를 보고하고자 한다. 증례요약: 65세 남자가 2년 전부터 간헐 양안 수직 복시가 있었으나 별다른 치료 없이 지내다가 2주 전부터 항상 증상이 생겨 내원하였다. 1달 전 진단받은 당뇨 이외에 다른 전신질환의 과거력은 없었다. 시력은 우안 20/25, 좌안 20/20이었고, 상대구심동공운동장애는 없었다. 안구운동검사에서 원거리 주시에서 4프리즘디옵터(prism diopters, PD)의 좌안 상사시와 근거리에서 4PD의 외사시를 보였다. 좌안은 내전시상전(elevation in adduction)이 있었다. 머리기울임검사에서 좌측 기울임에서 6PD의 좌안 상사시가 보였고, 우측 기울임에서는 정위를 보였다. 안저검사에서 우안 외회선과 좌안 내회선이 보였다. 뇌자기공명영상(brain magnetic resonance imaging)에서 중뇌 등쪽에서 나오는 도르래신경에 인접한 사구수조지방종을 확인하였다. 복시 증상의 완화를 위해 프리즘 안경을처방하였고, 다른 신경 증상을 동반하지 않아 뇌 병변에 대한 경과관찰을 시행하기로 하였다. 결론: 중뇌 등쪽의 사구수조지방종으로 인해 도르래신경마비를 확인하였다. 종양의 압박에 의한 도르래신경마비는 드물지만, 본 증례와 같이 비특이적인 증상을 보인 도르래신경마비 환자에서는 빠른 뇌영상검사가 원인 감별에 도움을 줄 수 있다. Purpose: To report a case of trochlear nerve palsy caused by quadrigeminal cistern lipoma located in the dorsal midbrain. Case summary: A 65-year-old male visited our clinic for intermittent vertical diplopia over 2-year period. Symptoms of diplopia had worsened over the past two weeks. He had no previous medical history except having had diabetes for 1 month. The bestcorrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. Pupillary examination was not remarkable. Extraocular examination showed 4 prism diopters (PD) left hypertropia at distant gaze and 4 PD exotropia at near gaze, with adduction elevation of the left eye. The Bielschowsky head tilt test revealed 6 PD left hypertropia on the left gaze and orthotropia on the right tilt. Fundus examination showed excyclotorsion of the right eye and incyclotorsion of the left eye. Brain magnetic resonance imaging revealed quadrigeminal cistern lipoma. Prism glasses were prescribed to alleviate diplopia, and we followed up the lesions without further treatment. Conclusions: Trochlear nerve palsy can be caused by quadrigeminal cistern lipoma; however, it is uncommon for this condition to be caused by a compressive lesion. Prompt neuroimaging can be helpful to rule out the causes of this condition in patients with atypical symptoms.

안부대상포진에서 헤르페스성 포도막염을 동반한 단안 활차신경마비 1예

이상곤(Jeffrey Lee),김수진(Su Jin Kim) 대한검안학회 2016 Annals of optometry and contact lens Vol.15 No.4

Purpose: To report a case of unilateral trochlear nerve palsy with herpetic uveitis in herpes zoster ophthalmicus. Case summary: A 67-year-old man presented with binocular diplopia of 4 days duration. He has been diagnosed with herpes zoster ophthalmicus based on the vesicles on left forehead and periocular area with accompanying pain, and has been taken antiviral agents and steroid for 4 days. Anterior chamber reaction was seen in left eye on slit lamp examination and extorsion of left eye was seen on fundus examination. He was diagnosed with trochlear nerve palsy based on the limitation of infraduction in the adducted position in left eye, and hypertropia in left eye, which is, aggravated by adduction of left eye and head tilt to the left. He was treated with antiviral agents and steroid and complete resolution of ophthalmoplegia occurred after 2 months of treatment. Conclusions: Unilateral trochlear nerve palsy with herpetic uveitis can occur in herpes zoster ophthalmicus and can be improved with antiviral agents and steroid.

뇌조조영술 후 발생한 양측 활차신경마비 1예

김근해,윤숙현,김숙영,Keun Hae Kim,MD,PhD,Sook Hyun Yoon,MD,Sook Young Kim,MD,PhD 대한안과학회 2014 대한안과학회지 Vol.55 No.1

Purpose: To report a case of bilateral trochlear nerve palsy following cisternography. Case summary: A 43-year-old male with intermittent watery rhinorrhea persisting for 3 months visited the neurosurgery department of our institute. His past medical history included removal of a pituitary adenoma 22 years prior to presentation. Cerebrospinal fluid leakage was suspected and cisternography was performed. The patient was referred to our ophthalmology department for diplopia 3 days after the cisternography. An alternate prism cover test showed 5 prism diopter (PD) right hypertrophia in the primary position, and underaction of bilateral superior oblique muscles and overaction of the left inferior oblique muscle. A positive Bielschowsky test with the head tilted to either side was observed and excyclotorsion was 9° on the double Maddox rod test. The patient was diagnosed with bilateral trochlear nerve palsy. After 2 years of follow- up, diplopia persisted and recession of the bilateral inferior oblique muscles was performed. After the surgery, diplopia disappeared, the fundus photography showed no excyclotorsion, and the double Maddox rod test indicated 3° of excyclotorsion. Conclusions: Cisternography should be carefully performed due to the possibility of bilateral trochlear nerve palsy, an extremely rare but possible occurrence following the procedure. J Korean Ophthalmol Soc 2014;55(1):155-160