FROZEN SECTION: GLIOBLASTOMA MULTIFORME, GRADE IV.
RIGHT ANTERIOR TEMPORAL LOBE RESECTED.
Aberrant Regeneration of the Third Nerve
Congenital, trauma, tumors, aneurysm, migraine.
Ischemia is exceptionally rare cause.
Globe retraction in upgaze , miosis on adduction (pseudo light-near dissociation).
MRI/MRA in all patients with non-traumatic cases of third nerve palsy or presumed “ischemic” third nerve palsy.
Evaluation of Isolated TNP Complete Partial Pupil involved ? No Ischemic risk factors ? Yes Observe MRI/MRA (or CTA) Yes Pupil involved ? Yes No Re-evaluate after 1 week involved spared Observe if ischemic risk factors, otherwise consider Imaging, LP Modified from clinical pathways in neuro-ophthalmology , AG Lee
PUPIL SPARING REPORTED IN 8-15% OF III-PALSY DUE TO ANEURYSMS PUPIL SPARING CN III PALSY 10 YEARS OLD MRI / MRA 20 YEARS OLD MRI / MRA, ? A-GRAM 40 YEARS OLD MRI / MRA, ? A-GRAM 60 YEARS OLD B/P, FBS, ?ESR, FOLLOW DAILY
50 year old with history of intermittent “double vision” for 8 months.
No headache, no vision loss.
VA 20/20 OU.
IOP 13mm/Hg OU.
Normal color plates.
Hertel Exo OD 17 OS 18 Base 100.
Different scenario Pseudo Von-Graffe’s sign Lid retraction in adduction
MRA WILL PICK UP 95% OF ANEURYSMS > 3mm MRA CONVENTIONAL A-GRAM
CTA or MRA ? 5-6 mm aneurysms can be missed Aneurysm detection Evaluation of Neck vessels Flexibility of display Contrast Patients with implanted metal Scanning time Superior Problematic Superior Not necessary in 3D TOF and 2D TOF Iodinated contrast Contraindicated Can be used Longer Short MRA CTA
A 73 year old lady referred by a neurosurgeon.
History of “double vision” for 3 months (horizontal and binocular) , worse when she looks to the left.
Has seen a neurologist , who ordered an MRI showed “intracranial meningiomas” of the falx, and left hemisphere.
Does not see double when she wakes up AM for an hour.
Patient reported that she is getting “tired” real quickly and unable to do “any work in the house”. Feels her legs and arms are “heavy”.
Case 23 Orbicularis weakness OD >OS
Always remember !
Ocular myasthyenia gravis.
Imaging for isolated Non-traumatic TNP
Children < 10 years : MRI/MRA regardless of pupil status.
10-50 year old with pupillary sparing and no vascular risk factors: MRI/MRA if normal medical evaluation and observe.
If aberrant regeneration: MRI/MRA with contrast.
With pupillary involvement if MRI/MRA is normal Cerebral angiography.