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Supernuclear ocular motor lesion that produce strabismus and diplopia
- skew deviation
- alternating skew deviation
- ocular tilt reaction
- thalamic esodeviation
- convergence insufficiency/spasm
- divergence insufficiency
Differentiate between skew, SO palsy and normal eye movement with head tilt.
- Normal: Tilt head -thus counter rolling of the eyes thus upper poles of the eye go the opposite way of the head tilt
- Skew: Head tilt, toward hypotropic eye, awat from hypertropic eye, but counter rolling is opposite from normal response in that hypotropic eye is excyclotorted/hypertropic eye incyclotorted
- SO palsy: Compensatory Head Tilt contralateral hypertropic eye (same as skew), but higher eye is excyclotorted, Head tilt worst to ipsilateral side, Hypotropia also worse on left gaze.
What is the triad for ocular tilt reaction?
- head tilt
- skew deviation
- ocular torsion
What does the Medical longitudinal fasciculus (MLF) do?
connects the CN6 nucleus (contralateral) with medial rectus subnucleus (ipsilateral) of CN3
What is Internuclear ophthalmoplegia (INO)? What are other finding in INO?
- Lesion to the MLF that limits adduction in the eye ipsilateral to the lesion and adduction nystagmus in contralateral eye
- skew deviation
What are finding in an WEBINO wall eyed bilateral INO?
- Bilateral adducting deficit
- Bilateral abducting nystagmus
- Nystagmus in upgaze
What are most common cause of INO and where in the brain is lesion?
- young adults -MS
- older adults-Stroke
What is one and a half syndrome?
Where is the lesion?
- ispilateral gaze palsy as side of lesion
- abducting nystagmus contralateral
- adduction deficit same side of lesion
- PONS affecting the PPRF & MLF
Nuclear palsy: 3rd nerve findings? and why?
- contralateral SR paresis
- bilateral ptosis
- both pupil or neither
- 1 subnucleus midline supplies both levator and SR subnucleus supply contralateral SR. Edinger Westphal nucleus supply both pupil
Cerebral peduncle and CN3 give what symptons and name of syndrome
- Weber Syndrome
Fasical Lesion- 3rd Nerve: red nucleus cause what symptoms and called?
- Benedikts syndrome
- ipsilateral 3rd nerve paresis
- contralateral hemitremor
Fasical Lesion- 3rd Nerve: Superior Cerebellar Peduncle cause what symptoms and called?
- Nothnagel syndrome
- ipsilateral 3rd palsy
- contralateral cerebellar ataxia
Combination of Nothnagel and Webers Syndrome
- Claude'sipsilateral 3rd nerve palsy
- Contralateral ataxia
Uncal herniation at the tentorium cerebeli causing compression of 3rd nerve give what finding?
Fixed dilated pupil in unconscious patient
Pupil involving 3rd nerve palsy
- secondary to aneurysm at junction of PCOM and carotid artery compression
- Can be painful
What CN involved in Cavernous Sinus syndrome
- 3, 4,V1, 6
- can be pupil sparing
- 1. CN3
- 2. CN4
- 3. CN 6
- 4. V1
- 5. V2
- 6. sympathetics
- 7. internal carotid
Why is the pupil spared in 3rd nerve parasis such as in DM
Pupil fiber outside and EOM fiber inside. Ischemia comes from inside first thus EOM affected and not pupil fibers.
Orbital syndrome associated with?
- optic nerve, 3,4,V1, 6
- CN3 splits after passing into SO thus palsy can be partial or complete
SO palsy and contralateral horners
CN 4 Nuclear /fasicular syndrome
How do you check CN4 in the setting of CN3 palsy
- ABDUCT the eye the have patient look down,
- the eye should intort
Describe findings in SO palsy? With the below example right SO?
What are Left gaze findings
Right head tilt
What is the torsion of the right eye?
Which eye is the higher eye?
- worse in left gaze (worse on contralateral gaze)
- worse in right head tilt (worse on ipsi head tilt)
- worse in down gaze
- right is excyclotorted
- right eye
What is found in Bilateral SO palsy?
- crossed hypertropia
- excyclotorsion of >10 degrees
- Large V pattern ET
Nuclear Lesion CN6
horizontal gaze palsy
Brainstem fasicle CN6 and CN7 pyrimidal tract cause what findings
- CN6/7 palsy
- contralateral hemiparesis
- Miller Gubler syndrome
CN 6 fasicle /pyrimidal tract only
- Contra paresis
- CN 6 palsy
WHich syndrome includes a Horners, horizontal gaze palsy, and CN 5,6,7
Increase ICP in the subdural space can cause a 6th nerve also due to?
Dorello's canal at 6 exits the pons
Chronic inflammation of petrous bone may cause CN 6 palsy, facial pain
Gradenigo syndrome in child with ear infections
Pseudo-gradenigo syndrome causes
- Nasopharyneal Cancer
- Cerebellopontine angle
- Petrous bone fracture
- Basilar aneurysm
What is the dx of a 6th nerve palsy patients <50?
- Tumor- MRI
- Myathenia Gravis
What is Tolosa Hunt Syndrome?
dx of exclusion sterile inflammation of cavernous sinus with pain. Resolves with steroids.
Congenital Fibrous syndrome
- bilateral ptosis
- external ophthalmoplegia
agenesis of CN6 nucleus with regeneration to the CN3
- overaction of muscle
- side effect to radiation to skull base
- treat with carbamazepine
Describe oculogyric crisis.
bilateral tonic deviation of eyes post phenothiazines. dopa blockers/parkinsons