Neurotutorial15 October 2015

Cranial neuropathy part INeuroopthalmology

Cranial neuropathy

Mononeuropathy

Monocular visual loss

Horner syndromeIsolated 3,4,6 palsy

Vestibular palsy

Trigeminal neuralgiaFacial n palsy

Multiple neuropathy

Cavernous sinus syndrome

et.al

Cerebellopontine angle syndrome

et.al

Jugular foramen syndrome

et.al

With long tract sign

Weber syndromeet al

Millard Gruber syndrome

et.al

Wallenberg syndrome

et al

Exclude Apraxia, NMJ, Muscle

• Female 40 year old with UD hypertension complaints progressive Rt.eye pain on eye movement for 5 days with central blurry vision. Examination found pupil 2 mm both eyes but poorly react Rt.side. Rt. VA 20/60, Lt VA 20/20. Eye ground exam have no papilledema or exudate. MRI with gad of brain is normal. What is the most appropriate management.

A. ASA 300 mg B. Oral prednisolone C. Observe and FU 3 weeks. D. Intravenous methyprednisolone

Optic neritis

• Monocular visual loss • Anterior to optic chiasm• Impaired VA• Impaired light reflex

• Binocular visual loss

• Retrochiasm• Not impair VA (unless bilat lesion)• Not impair light reflex ( Retrogeniculate body)

Blurr disc – hard to diff from papilledema ( usualy bilat involve)

Acute monocular visual loss

Typical for MS*

Demyelination

High risk for MD(60-90%)

Normal

Low risk for MS. (20%)

MRI brain +/- LP

Atypical for MS

Work up for mimickerLP, Serology, CT/MRI

Clinical,Eye ground

Adapted from Bermel RA, Continuum . 2013 Aug;19(4 Multiple Sclerosis):1074-86

IVMP: if VA worse than 20/40, disabling scotoma,severe pain

• NMO (more bilat, less pain,less recover)• Ishemic : AION• Inflamatory : esp Giant cell arthritis• Infiltrative : Malignancy• Infection : Syphilis, CMV neuroretinitis• Hereditarty

• Unilat • Pain on movement• Partial : color, contrast, scotoma• Normal disc (most) or mild swelling• Progressive days to weeks

Typical sign and symptom of MS optic neuritis

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IVMP in optic neuritis

• IVMP 250 mg, 6 hourly 3 days,followed by Oral pred (1 mg\kg\d) 11 days tapering of prednisolone within 3 days

• The optic neuritis ONTT -compares oral placebo, IVMP, Oral stearoid

• IVMP -> Faster recovering vision (but no long term impact)-> Slower progress to be definite MS

Male 70 years-old complain shoulder and headache for 1 dayThe eye examination as the picture. The Lt. pupil is reactive but delayed dilatation after dimmed light. Other wise examination is normalWhat would be investigation of choice.

A. Chest X-rayB. US carotid a.C. CT brain angiogramD. CT brain with contrastE. Refer ophthalmologist for cocain test

Horner syndrome

Sympathetic paralysis -> look lazy - Mild ptosis - Mild anisocherea :dilate lag in the dark - May anhidrotic : 1st and 2nd order

Anisochorea = Inequal pupil

• Sympathetic -> dilate eye in the dark Defect side -> dilation lag“ Aniso in the dark”

• Parasympathetic -> constrict in light

Defect side -> Non react dilated “Aniso in the light”

• Physiology = no change

Anisochorea

• Anisochorea never caused by optic nervedue to consensual reflex: if optic n. defect -> smaller pupil both

Aniso in the dark: Sens 70% Spec 95%

Aniso in the light + Non reactive pupil

After mydriasin drop

No change

Horner syndrome

1st : Descending tract from hypothalamus:intermediolat corlumn near corticosponal tract

2nd : Preganglionicapical lung - ciliospinal center of budge C8

3rd : Post ganglionicbifurcate of internal and external carotid a.

1

2

3

Any combination of ptosis, miosis or anhidrosis -> suspect Horner syndrome (HS)

Acute onset , Painful, Trauma, UD Malignancy

Without long tract sign

2nd or 3rd HS-> CTA/MRA E:

HS protocal

With long tract sign

1st order HS-> MRI brain E.

Chronic

Confirm by Cocain & Methylphenidate

Delayed dilation in the dark

Adapted from Davagnanam I ,Eye (Lond). 2013 Mar;27(3):291-8

Pharmacologic test

Specificity 100%

But need 24 hrs for testing

Female 50 years-old underlying diabetes complain painless diplopia when look to the right side for 1 week. The eye examination in primary position as the picture. EOM limited adduction 60%, upgaze 80% downgaze 80%. The Rt pupil is 3 mm while Lt. 4 mm sluggish react to light. Other wise examination is normal.What would be investigation of choice.

A. FBSB. Ice pack testC. CT brain angiogramD. CT brain venogramE. CSF for NMO antibody

Isolated 3rd nerve palsy

Oculomotor n. go along with parasym - Ptosis - Opthalmoplegia - May dilated and non react to the light : 20% of vasculopathy 80% of compressive -> severity of pupil involvement usually correlate with severity of opthalmoplegia

PCOManeurysm

3rd nerve palsy almost always consider imaging R/O PCOMpupil sparing in ‘partial’ ophthalmoplegia cannot R/O

only pupil sparing in ‘complete’ opthalmoplegia likely R/O

Isolated 4th nerve palsy

Oculomotor n. go along with parasym - Ptosis more obvious - Opthalmoplegia - May dilated and non react to the light : 20% of vasculopathy 80% of compressive -> severity of pupil involvement usually correlate with severity of opthalmoplegia

Isolated 6th nerve palsy

Oculomotor n. go along with parasym - Ptosis more obvious - Opthalmoplegia - May dilated and non react to the light : 20% of vasculopathy 80% of compressive -> severity of pupil involvement usually correlate with severity of opthalmoplegia

Binocular diplopia

Isolated CN 3 palsy

Without long tract sign

2nd or 3rd HS-> CTA/MRA E:

HS protocal

With long tract sign

1st order HS-> MRI brain E.

Isolated CN 4 palsy

DM, HTFU 3-6 mo

Isolated CN 6 palsy

WU focused malignancy

Adapted from Davagnanam I ,Eye (Lond). 2013 Mar;27(3):291-8