Neurotutorial
15 October
2015
Cranial neuropathy part
I
Neuroopthalmology
Cranial neuropathy
Exclude Apraxia, NMJ, Muscle
Mononeuropat
hy
Multiple
neuropathy
With long
tract sign
Monocular
visual loss
Cavernous sinus
syndrome
et.al
Weber
syndrome
et al
Horner
syndrome
Isolated 3,4,6
palsy
Vestibular palsy
Cerebellopontin
e angle
syndrome
et.al
Millard Gruber
syndrome
et.al
Trigeminal
neuralgia
Facial n palsy
Jugular foramen
syndrome
et.al
Wallenberg
syndrome
et al
Female 40 year old with UD hypertension com
plaints progressive Rt.eye pain on eye movem
ent for 5 days with central blurry vision. Exami
nation found pupil 2 mm both eyes but poorly
react Rt.side. Rt. VA 20/60, Lt VA 20/20. Eye g
round exam have no papilledema or exudate.
MRI with gad of brain is normal. What is the m
ost 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
Clinical,
Eye ground
Typical for
MS*
Atypical for
MS
MRI brain
+/- LP
Normal
Demyelinatio
n
IVMP: if VA worse than 20/40,
disabling scotoma,severe pain
Low risk for
MS. (20%)
High risk for
MD
(60-90%)
Work up for
mimicker
LP, Serology,
CT/MRI
NMO (more bilat, less pain,less
recover)
Ishemic : AION
Inflamatory : esp Giant cell
arthritis
Infiltrative : Malignancy
Infection : Syphilis, CMV
neuroretinitis
Hereditarty
Adapted from Bermel RA, Continuum .2013 Aug;19(4 Multiple
Typical sign and
symptom of MS optic
neuritis
Unilat
Pain on movement
Partial : color, contrast, scotoma
Normal disc (most) or mild
swelling
Progressive days to weeks
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 day
The eye examination as the picture. The Lt. pupil is reactive but
delayed dilatation after dimmed light. Other wise examination
is normal
What would be investigation of choice.
A.
B.
C.
D.
E.
Chest X-ray
US carotid a.
CT brain angiogram
CT brain with contrast
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
nerve
due to consensual reflex
: if optic n. defect -> smaller pupil bo
th
Aniso in the dark: Sens 70% Spec
95%
After mydriasin drop
Aniso in the light + Non reactive
pupil
No change
Horner
syndrome
1st : Descending
tract from
hypothalamus
3
:intermediolat corlumn
near corticosponal tract
2nd :
Preganglionic
apical lung - ciliospinal
center of budge C8
3rd : Post
ganglionic
Any combination of ptosis, miosis or
anhidrosis -> suspect Horner
syndrome (HS)
Delayed
dilation in
the dark
Acute onset ,
Painful,
Trauma, UD
Malignancy
With long
tract sign
1 order HS
-> MRI brain
E.
st
Without long
tract sign
Chronic
Confirm by
Cocain &
Methylphenidate
2nd or 3rd HS
-> CTA/MRA
E:
HS protocal
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.
B.
C.
D.
E.
FBS
Ice pack test
CT brain angiogram
CT brain venogram
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
PC
O
an M
ys eu
m r
3rd nerve palsy almost always consider imaging R/O PCOM
pupil 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
With long
tract sign
1 order HS
-> MRI brain
E.
st
Isolated CN 4
palsy
Without long
tract sign
DM, HT
FU 3-6 mo
Isolated CN 6
palsy
WU focused
malignancy
2nd or 3rd HS
-> CTA/MRA
E:
HS protocal
Adapted from Davagnanam I ,Eye (Lond).2013 Mar;27(3):291-8
