1) Visual disturbances can be caused by lesions along the optic tracts or oculomotor pathways in the brain. 2) MRI is the primary imaging modality used to identify lesions, with protocols directed by clinical findings. Small lesions can have significant effects. 3) Examples include posterior optic nerve edema after head trauma causing immediate visual loss, and left optic tract atrophy found on MRI explaining old right homonymous lateral hemianopia from prior severe head trauma. Careful analysis of MRI images is important since lesions may be very small.

1. VISUAL DISTURBANCIES
KEY POINTS
F Heran and the team of the imaging department
Founda2on Rothschild - PARIS
Hanoi 2015

2. VISION
See (op2c tracts) and
Look at (oculomotor pathways)
VISION Re2naè occipital cortex
Op4c tracts, op4c radia4ons è HLH***
Re4na Op4c nerve è VAL*
Op4c Chiasm è BTH **
* Visual accuity loss
** Bitemporal hemi anopia
*** Homolateral hemi anopia

3. OCCULOMOTRICITY
Brain stemè orbit
VI
III
IV
III
VI
IV
III
VI
IV

4. IMAGING KEYS
Clinical approach Quality of the images
Mo4va4on of the pa4ent and the technician
DIAGNOSIS

5. VISION

6. IMMEDIATE POST TRAUMA VISUAL LOSS
CT Scan : must be performed in emergency (compressive
small bone fragment ?)
MRI may find abnormal signal of the op2c nerve sugges2ve of edema.
Bad prognosis, no surgery needed.

7. Urolagin SB Kotrashe1 SM, Kale TP Balihallimath LJ Trauma:c op:c neuropathy a>er maxillofacial trauma: a review
of 8 cases. J Oral Maxillofac Surg.2012
MRI: in case of absence of fracture.
Diagnosis keys: hypersignal T2/PD linear area, perpendicular to the op:c
nerve axis, near the apical segment.
A very interes2ng sequence : 3D proton density
Benoit 32 year-old, acute post trauma visual loss
Op2c nerve sec2on (è)
SECTION OF THE OPTIC NERVE

8. Anterior Ischemic Optic Neuropathy (AION):
ischemia of the optic nerve or the retina
Left AION
Odette 75 year-old Left acute visual loss
PROTOCOL ? Acute ischemia
Looking for an acute stroke. Brain and optic nerve or retina
L R
L
IRREVERSIBLE BRUTAL ACUTE VISUAL LOSS

9. Hayreh SS, Visual field abnormali:es in nonarteri:c anterior ischemic op:c neuropathy: their paQern and prevalence
at ini:al examina:on. Arch Ophthalmol.2005
LeX papilla acute ischemia (è)
B1000 ADC
LeX op2c nerve acute ischemia (è). Very seldom !
Diagnosis keys : Al2tudinal deficit of the visual field, papilloedema,
diffusion.
ADC B1000

10. UNI OR BILATERAL OPTIC DISK EDEMA
Isolated ? Think of papillary drüsen
CT scan or MRI ? Have a look at the op2c bulb
BhaQ UK Bilateral op1c disc swelling; is a CT scan necessary? Emerg Med J.2005
RoQ D, Leibowitz D. Op:c nerve head drusen mimicking papilledema and malignant
hypertension. Eur J Intern Med. 2009
0,5 to 2% of the causasian popula2on, bilateral in 75 %
of the cases
Hyalinic pre papillar deposits, with extrusion of axonal
material, either deep (imaging) or superficial ( fundus).
70% : loss of peripheral visual (focal ischemia).

11. Visual loss, 4nitus, headache ? Only one diagnosis,
intracranial hypertension (ICHT)
Rule of the three T
Venous Thrombosis
Tumor
Too much sweets and candies
BhaQ UK Bilateral op1c disc swelling; is a CT scan necessary? Emerg Med J.2005
RoQ D, Leibowitz D. Op:c nerve head drusen mimicking papilledema and malignant hypertension. Eur J Intern Med.
2009

12. IDIOPATHIC INTRACRANIAL HYPERTENSION
Nelly, 29 year-old, is working in Paris for 6 months, and gained 12 kg.
Complains of visual disturbances (liele spots)
Examina2on: major op2c disk edema, visual loss (leX side 5/10 and
right side 4/10).

13. Woodall MN Bilateral transverse sinus stenosis causing intracranial hypertension. BMJ Case Rep.2013
Riggeal BD Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis. Neurology. 2013
Lumbar punc2on: diagnosis (p> 20 cm H2O, 25 cm
of obese) and draining
Diagnosis keys: MRI, Lumbar punc:on with pression measure
Arachnoidocele,
cerebellar tonsils ptosis
Periop2c spaces dilata2on
Hyperpersignal T2 of the op2c
nerves
Lateral sinuses stenosis

14. NORMAL PRESSION GLAUCOMA
Claude, 63 year-old, right visual loss, papillary excava2on, normal ocular pression.
PROGRESSIVE VISUAL LOSS, MORE OR LESS INCIDIOUS
Zhang YQ, et al Anterior visual pathway assessment by magne:c resonance imaging in normal-pressure glaucoma. Acta
Ophthalmol. 2012
Diagnosis keys: op:c chiasma atrophy, papillary excava:on.
VF : tubular
Bertrand A Open-Angle Glaucoma and Paraop:c Cyst: First Descrip:on of a Series of 11 Pa:ents. AJNR Am J Neuroradiol.
2015

15. LEBER DISEASE
Ong E Teaching neuroimages: chiasmal enlargement and enhancement in Leber hereditary op:c neuropathy. Neurology.
2013
Lamirel C papilloedema and MRI enhancement of the prechiasmal op:c nerve at the acute stage of Leber hereditary op:c
neuropathy. J Neurol Neurosurg Psychiatry.2010
Oscar, 28 year-old, painless bilateral visual loss. Fundus : papilledema with hyperemia
MRI : hypersignal T2 and FLAIR of the op2c chiasm and the op2c tracts (è), enhancement of the leX
op2c chiasm. (è).
T2 T2T2
T1 Gd FLAIR
Diagnos1c keys: young man, bilateral visual loss some:mes very severe, MRI: op:c atrophy,
inflammatory aspect if the op:c nerves and/or the op:c chiasm (more seldom), search for
mitochondrial DNA muta:on.

16. Mainly due to op2c chiasm compression
Typical visual field (black = the pa2ent sees nothing)
BITEMPORAL HEMIANOPIA (BTH)
PITUITARY
MACROADENOMA ?

17. HYPOPHYSITIS
Nathalie, 27 year-old,
3 months post
partum, BTH and
headache
Diagnosis keys : clinical data, MRI signs
Nakata Y, Parasellar T2 dark sign on MR imaging in pa:ents with lymphocy:c hypophysi:s. AJNR 2010
Gutenberg A. A radiologic score to dis:nguish autoimmune hypophysi:s from nonsecre:ng pituitary adenoma
preopera:vely. AJNR2009
Grunberg AJNR 2009 Adénome NS Hypophysite
< 30 year-old N O
Rela4on to pregnancy N O
Huge lesion (> 6cm3) O N
Symmetrical N O
Intense and homogeneous enhancement è N O
Posterior pituitary bright spot Lost è N O
Thick pituitary stalk è N O
« Dark sign » è N O

18. Subbiah S Acrogigan:sm and facial asymmetry: McCune-Albright syndrome. J Pediatr Endocrinol Metab.2011
MAC CUNE ALBRIGHT
Grégoire, 32 year-old, progressive visual loss with recent headache
Diagnosis keys : Polyosto:c fibrous dysplasia , café au lait spots, pituitary adenoma,
precocious puberty.

19. CHORDOIDE GLIOMA
T1 T2 T1 Gd Fat Sat T2
Roland, 63 year-old. Progressive visual loss. BTH. Huge suprasellar suprachiasma2c
lesion (è) with mass effect on the op2c chiasm (è).
Pomper MG Chordoid glioma: a neoplasm unique to the hypothalamus and anterior third ventricle. AJNR 2001
Diagnosis keys : Well defined ovoid hypothalamic/ anterior third ventricle mass,
showing a strong enhancement.

20. Myopia is associated to increased globe size and posterior deforma4on
(staphyloma). This abnormal shape may be responsible for BTH.
Manfrè L, Vero S, Focarelli-Barone C Lagalla R Bitemporal pseudohemianopia related to the ":lted disk" syndrome: CT,
MR, and fundoscopic findings. AJNR 1999
Oblique inser2on of the op2c nerve head
Nasal area ectasia, thinning of the posterior wall (è)
Flaeening of the temporal part of the globe (è)
MYOPIC DEFORMATION
Eric, 52 year-old , BTH disclosed during systema2c examina2on. Strong myopia
(> -6 dioptries).
Diagnosis keys: globe shape, no other cause
T2

21. The lesion is located behind the op4c chiasm, opposite to the
injured visual field.
Among the usual loca4on, don’t forget the op4c tract !
HOMONYMOUS LATERAL HEMI (QUADR) ANOPIA
POST TRAUMA
ATROPHY
Sylvia, 42 year-old. Right HLH.
MRI : LeX op2c tract atrophy. History
of severe head trauma. Sequels (è).

22. INFLAMMATION OF THE OPTIC TRACT : MULTIPLE SCLEROSIS
Barbara 36 year-old, right homonymous lateral quadranopia
disclosed at the awakening . Visual field altera2on (è).
MRI in emergency, looking for a stroke, seems normal.
T2
Right eye LeX eye
FLAIR T1 Gd T2 FATSAT
A more focused examina2on finds a leX op2c tract lesion (è)

23. OCULOMOTRICITY

24. INFLAMMATION OF THE III
(Sarcoïdosis)
Gabrielle, 46 year-old Ver2cal diplopia associated to right orbital pain for the last
three months. Progressive worsening. 2 MRI performed, disclosing no lesion.
VERTICAL DIPLOPIA
Diagnosis keys: inflammatory signs, enlarged IIIrd cranial nerve, with hypersignal
T2 and enhancement

25. Morphometry of the trochlear nerve and superior oblique muscle volume in congenital superior oblique palsy. Invest
Ophthalmol Vis Sci.2014 Nov
Nathan, 12 year-old. Head trauma during a football game. Immediate oblique diplopia,
obvious during reading and descent of stairs.
Brain MRI is normal Orbit MRI is performed.
Diagnos1c keys : family pictures, head bent on one side opposite to the superior oblique muscle
atrophy, normal brain MRI,
SUDDEN OBLIQUE DIPLOPIA
Head bent toward the right
Side, opposite to the extraocular
muscle palsy
It reveals a leX superior oblique atrophy (è).
IV th Cranial nerve
lesion

26. In some cases, a possible cause is discovered, such as this lipoma at the
emergence of the nerve

27. TO SEE and TO LOOK AT: what else ?
Imaging is mainly performed with MRI
The protocol must be directed by clinical data.
Analysis of the images should be
Careful, as the lesion may be very small
Demanding, based on a confident relationship with
patient and technician to avoid movement artifacts et
protocol errors
Vision : differentiation between anterior and posterior (behind
the optic chiasm) optic pathways.
Oculomotricity, don’t forget to have a look at the orbital
components.
And small lesion big effects.

28. More frequent mechanism, a posterior head trauma.