Isolated Palsies of Cranial Nerves III, IV, and VI

Brazis, Paul W.

doi:10.1055/s-0028-1124019

Cited by 80 publications

(50 citation statements)

References 98 publications

(122 reference statements)

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“…2,4,10,11 The head tilt occurs in approximately 70% of all patients, whereas the paradoxic tilt affects only 3% of patients. 5 A unique feature of this case is that the patient developed a same-sided (paradoxic) head tilt rather than the more common contralateral head tilt. Certified athletic trainers and other sports medicine professionals should be aware that these types of compensations can signal a CN injury.…”

Section: Discussionmentioning

confidence: 99%

“…5 Once structural damage to the brain has been ruled out, few treatment options exist for CN IV palsy. When encountering sudden-onset isolated CN IV palsy, one should delay prescribing permanent prism glasses for at least 3 months in order to allow the palsy to recover.…”

Section: Discussionmentioning

confidence: 99%

“…The nerve exits the brain stem dorsally into the subarachnoid space, then courses around the brain to enter the cavernous sinus, superior orbital fissure, and orbit and to innervate the superior oblique muscle. 4,5 This muscle's actions include rotation in the vertical plane (depression and elevation of the eyeball) and rotation in the plane of the face (intorsion and extorsion of the eyeball). The force of the tendon's pull, therefore, has 2 components: a forward component that tends to pull the eyeball downward (depression) and a medial component that tends to rotate the top of the eyeball toward the nose (intorsion).…”

Section: Discussionmentioning

confidence: 99%

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Fourth Cranial Nerve Palsy in a Collegiate Lacrosse Player: A Case Report

Stiller-Ostrowski

2010

Journal of Athletic Training

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Objective: To present the case of a National Collegiate Athletic Association Division I men's lacrosse athlete with fourth cranial nerve injury as the result of a minor traumatic blow.Background: The athlete was struck on the right side of his head during a lacrosse game. On-field evaluation revealed no cervical spine involvement or loss of consciousness. He complained of headache and dizziness, with delayed reports of visual disturbance. Sideline visual acuity and cranial nerve screenings appeared within normal limits. Consultation with the team physician indicated that immediate referral to the emergency department was unnecessary.Differential Diagnosis: Concussion, third cranial nerve palsy, fourth cranial nerve palsy.Treatment: The certified athletic trainer safely removed the athlete from the playing field and monitored him on the sideline. After being seen by the team physician, the patient was referred to a neurologist, ophthalmologist, and finally a neuro-ophthalmologist before a definitive diagnosis was made. The palsy did not necessitate surgical intervention, resolving with conservative treatment. The athlete was able to return to full athletic ability at his preinjury level by 8 months postinjury.Uniqueness: Superior oblique palsy as the result of fourth cranial nerve injury is the most frequent isolated cranial nerve palsy; however, these palsies are often underdiagnosed by health professionals. Such palsies are uncommon within the athletic realm, making timely diagnosis even less likely.Conclusions: Cranial nerve palsy may present very subtly in patients. Therefore, on-field health care providers should be aware of the descriptions and types of compensations that signal nerve injury.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Fourth Cranial Nerve Palsy in a Collegiate Lacrosse Player: A Case Report

Stiller-Ostrowski

2010

Journal of Athletic Training

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“…If the CT scan is normal, lumbar puncture (LP) is required to investigate any bleeding or meningitis. Complete or incomplete third nerve palsy in addition to mydriasis, even without pain and regardless of the patient's age, must prompt urgent examination to search for carotid aneurysm [10,12]. Midbrain infarction or carotid cavernous fistula might be other challenging vascular causes.…”

Section: "Vascular Origin May Representmentioning

confidence: 99%

“…Given the relatively more frequent diagnosis of aneurysm in case of third nerve palsy (~15%) compared with sixth or fourth nerve palsy (1-3%), the rationale for choosing the more appropriate examination and the optimal timing will be different according to the ocular motor nerve involved [4][5][6]10].…”

Section: "Vascular Origin May Representmentioning

confidence: 99%

When is diplopia strongly suggestive of a vascular event?

Tilikete¹,

Vighetto²

2009

Expert Review of Ophthalmology

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Pupillary Disorders

Walsh¹,

Liu²

2012

Encyclopedia of Life Sciences

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Pupillary abnormalities range from benign isolated findings to harbingers of significant, even life‐threatening, conditions. A complete understanding of the neuroanatomy underlying the innervations to the antagonistic pupillary sphincter and dilator muscles is essential to detecting, and discerning the importance of, a particular pupillary abnormality. The sphincter muscle receives neuronal input from the parasympathetic division of the autonomic nervous system, whereas the dilator muscle receives input from the sympathetic division. Afferent input carrying light information to the brain is transmitted by retinal ganglion cell axons via the optic nerves, chiasm, and tracts. The parasympathetic innervation to the pupil originates in the Edinger‐Westphal nucleus in the midbrain. The sympathetic innervation to the pupil consists of a three‐neuron pathway originating in the hypothalamus. Important pupillary disorders include physiologic anisocoria, relative afferent pupillary defect, amaurotic pupil, Argyll Robertson pupils, cranial nerve III palsy, pharmacologic mydriasis, tonic pupil, and Horner syndrome. Key Concepts: Examination of the pupil is an important part of the physician's neurological and ophthalmological evaluation of a patient. The size of the pupil is controlled by the actions of antagonistic muscles located within the iris: the pupillary sphincter and dilator. Constriction of the pupils is mediated by the parasympathetic nervous system, whereas dilation of the pupils is mediated by the sympathetic nervous system. Pupillary constriction to light occurs via an involuntary reflex arc. Retinal ganglion cell axons involved in carrying light information for the pupillary light reflex exit the optic tract (proximal to the lateral geniculate nucleus) to synapse in the midbrain pretectal nucleus. The parasympathetic output controlling pupillary constriction originates in the Edinger‐Westphal nucleus in the midbrain and terminates at the pupil sphincter muscle. Pupillary dilation involves a ‘three‐neuron’ sympathetic pathway, which originates in the posterolateral hypothalamus and terminates at the pupil dilator muscle. A relative afferent pupillary defect is caused by a decreased amount of light information from the affected eye reaching the pretectal nuclei in the midbrain and is most commonly a sign of ipsilateral optic nerve pathology. Damage to cranial nerve III can result in injury to the parasympathetic fibres travelling to the pupillary sphincter muscle, thus disrupting the efferent arc of the pupillary light reflex, resulting in deficient pupillary constriction on the involved side. Horner syndrome, characterised by miosis, ptosis, and facial anhidrosis, results from disruption of the oculosympathetic pathway.

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Isolated Palsies of Cranial Nerves III, IV, and VI

Cited by 80 publications

References 98 publications

Fourth Cranial Nerve Palsy in a Collegiate Lacrosse Player: A Case Report

Fourth Cranial Nerve Palsy in a Collegiate Lacrosse Player: A Case Report

When is diplopia strongly suggestive of a vascular event?

Pupillary Disorders

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