What is the diagnosis?

Abduction Deficits

Abduction Deficits

STARTING IN THE BRAIN

1. supranuclear2. nuclear3. fascicular4. peripheral

1. cavernous sinus2. orbit

5. neuromuscular junction6. muscle

Abduction Deficits

Abduction Deficits

Abduction Deficits

Abduction Deficits

Abduction Deficits

Abduction Deficits

Abduction DeficitsCase 1

• 51 year-old man with highcholesterol:– late November – R-

sided headaches– early January –

horizontal, binocular diplopia in R- gaze

– late January – “whooshing” noise heard AU

• May – neuro-opappointment

-1/2 abduction deficits R & L, 2 mm proptosis OS and conjunctival hyperemia

•

Abduction DeficitsCase 1

• 51 year-old man with highcholesterol:– late November – R-

sided headaches– early January –

horizontal, binocular diplopia in R- gaze

– late January – “whooshing” noise heard AU

• May – neuro-opappointment

-1/2 abduction deficits R & L, 2 mm proptosis OS and conjunctival hyperemia

•

Abduction DeficitsCase 1

DIFFERENTIAL DIAGNOSIS

WHAT OTHER EXAM POINTS WOULD HELP NARROW THE

DIFFERENTIAL?

Abduction DeficitsCase 1

dark 5 seconds dark 15 seconds

Abduction DeficitsCase 1

Abduction DeficitsCase 2

• 21 year-old young woman with headaches for 4 months and double vision while looking off into the distance

• What else would youlike to ask her?

Abduction DeficitsCase 2

• 21 year-old young woman with headaches for 4 months and double vision while looking off into the distance

• What else would youlike to ask her?Opening pressure was 340 mm H20

Eventual shunt (failed DMX and Lasix)

Abduction DeficitsCase 3

• 39 year old woman with headaches and binocular, horizontal diplopia was treated by a local ophthalmologist for “idiopathic CN6 palsy” with prednisone and got better

• as the prednisone was tapered, she got worse – headache and “swelling around the left eye”

Abduction DeficitsCase 3

• 39 year old woman with steroid responsive headaches and binocular, horizontal diplopia

• What other parts of the exam/history would you like to know about?

Abduction DeficitsCase 3

Abduction DeficitsCase 4

• 64 year old woman with DM, HTN, hypothyroid with a history of diplopia for 10 years diagnosed as a L CN6

• she feels that her double vision is getting worse

Abduction DeficitsCase 4

• 64 year old woman with DM, HTN, hypothyroid with a history of progressive diplopia for 10 years diagnosed as a L CN6

• What do you think about the previous diagnosis?

Abduction DeficitsCase 4

64 year old woman with DM, HTN, hypothyroid with a history of progressive diplopia for 10 years diagnosed as a L CN6

• How long for ischemic cranial nerve palsy to resolve?

• What is isolated?• When to scan?• What to ask for on

scan?

Abduction DeficitsCase 4

64 year old woman with DM, HTN, hypothyroid with a history of progressive diplopia for 10 years diagnosed as a L CN6

• Possibility of Graves’ (she is on Synthroid)?– Most common

muscle/motility problem– External signs

Abduction DeficitsCase 4

Abduction DeficitsCase 5

• 52 year-old man awoke with R facial droop, felt unsteady next day Lhemiparesis

• Where is the lesion?

Abduction DeficitsCase 5

• Millard-Gubler (6 + 7 + contralateralhemiparesis) from vertebrobasilar thrombosis

• He also had cerebellar, occipital and thalamic infarcts

Abduction DeficitsCase 7

• Describe the photo

Abduction DeficitsCase 8

• 42 year old woman without any prior medical problems who had binocular, horizontal double vision for the past day

• Differential diagnosis

• What to do?

Abduction DeficitsCase 8

• Lesion in area of L CN6

fascicle - possibly demyelination• CSF was negative• It resolved completely

Abduction DeficitsCase 9

• 72 year old man with HTN, A-fib and the acute onset of binocular, horizontal diplopia

• Differential diagnosis

• What to do?

Abduction DeficitsCase 9

• 72 year old man with HTN, A-fib and the acute onset of binocular, horizontal diplopia

• After 2 months thediplopia is worsening

• What to do?

Abduction DeficitsCase 9

• MRI – R intracavernous carotid artery aneurysm

Abduction DeficitsCase 10

• 52 year old man with history of CABG, defibrillator, referred for progressive esotropia over 2-3 years

• Differential diagnosis

• What to do?

Abduction DeficitsCase 10

• Echo – AEL 34 and 36

Abduction DeficitsCase 11

• 17 year-old young man with hoarseness and difficulty swallowing was found to have a schwannoma near the right jugular foramen

• s/p resection with excision of the right jugular bulb he complained of binocular horizontal diplopia

• What do you suspect?

Abduction DeficitsCase 11

• 17 year-old young man with hoarseness and difficulty swallowing was found to have a schwannoma near the right jugular foramen

• s/p resection with excision of the right jugular bulb he complained of binocular horizontal diplopia

• What do you suspect?

Abduction DeficitsCase 11

• venous sinus thrombosis, reduced venous outflow with raised intracranial pressure and bilateral sixth nerve palsies

Abduction DeficitsCase 12

• 64 year old man with history of HTN, DM and prostate cancer with a complaint of binocular, horizontal diplopia at distance for 2 days, mild ptosis and periorbital pain

• Differential diagnosis

• What to do?

Abduction DeficitsCase 12

• Not isolated1. patient has history of disease that can cause the

cranial neuropathy2. ptosis and abduction deficit

• What do you think about the pain?

Abduction DeficitsCase 13

• 22 year-old young woman without diplopia

• What is the diagnosis?

Abduction DeficitsCase 14

• 26 year-old man with horizontal diplopia for 3 months

• What other questions do you want to ask him?

• Differential diagnosis

Abduction DeficitsCase 14

• 26 year-old man with horizontal diplopia for 3 months

• What other questions do you want to ask him?

• Differential diagnosis

Abduction DeficitsCase 14

• 26 year-old man with horizontal diplopia for 3 months

• MG

sfEMG

blocking and jitter of second action potential during voluntary activation of orbicularis muscle