Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment

Patients with isolated unilateral pupil-sparing third or isolated fourth or sixth nerve palsies over 50 years are often diagnosed with ''microvascular extraocular palsies''. This condition and its management provoke divergent opinions. We review the literature and describe the incidence, pathology, clinical presentation, yield of imaging, and management. A retrospective diagnosis of exclusion has little practical use. We suggest a pragmatic approach to diagnosis, investigation, and management from initial presentation.

mentioning

confidence: 99%

Microvascular Non-Arteritic Ocular Motor Nerve Palsies—What We Know and How Should We Treat?

Galtrey

Schön

Nitkunan

2014

“…This lack of agreement mirrors the conflicting conclusions of several series of ocular motor mononeuropathies in the recent literature. [9][10][11][12][13] Variant conclusions are not unexpected in these series due to their differing designs, study populations and imaging protocols. The only area of agreement in this section of the survey was for the case of a longstanding, decompensated, congenital IV nerve palsy where consensus was achieved that imaging was not normally performed.…”

Section: Discussionmentioning

confidence: 93%

The Urgency of Neuroimaging Among UK Neuro-Ophthalmologists: Consensus and Disagreement

Ali

Lau

Plant

2013

The timing of imaging in neuro-ophthalmology is critical. There are few published studies, however, that address the question of how urgently to request imaging for neuro-ophthalmic clinical scenarios. We therefore conducted a national survey of expert opinion on the urgency of neuroimaging in neuro-ophthalmology. We devised a list of 40 clinical scenarios, reflecting a wide range of neuro-ophthalmic presentations. For each scenario, respondents were asked to state how urgently they would obtain neuroimaging in day-to-day NHS (National Health Service) practice. There were five response options: ''Emergency'' (i.e., within 1 d), ''Urgent'' (i.e., within 1 week), ''Semi-urgent'' (i.e., within 1 month), ''Observation'' (only if not resolving after a period of observation [greater than 1 month]), and ''Not normally scanned unless new features appear.'' Respondents were recruited by e-mailing individuals who were on the UKNOSIG (UK Neuro-Ophthalmology Special Interest Group) mailing list. All were Consultant Ophthalmologists or Neurologists specialising in neuroophthalmology. Consensus was set at an a priori level of 80% agreement. Only 17 out of 40 scenarios met the criterion for consensus. Nine of these were for emergency/urgent imaging, three were for not imaging, and five were for semi-urgent imaging. For the remaining 23 scenarios, consensus was not reached. Unanimity (100% agreement) was not reached for any scenario. Agreement between neuro-ophthalmologists on the urgency of neuroimaging is patchy, with consensus for some clinical scenarios and disagreement for many. There is a need for a prospective study of neuroimaging in neuro-ophthalmology to determine whether timing of imaging influences outcomes.

“…However, immediate neuroimaging for isolated abducens nerve palsy is still warranted. 9,10 In cases of oculomotor palsy especially in cases with pupillary involvement, an immediate examination with neuroimaging is necessary to rule out the possibility that the palsy was caused by an aneurysm. 11 However, an aneurysm is a rare cause of abducens nerve palsy, with incidences of 3-4%, 12,13 and reports of cases with isolated unilateral abducens nerve palsy due to an aneurysm are still scarcer.…”

Section: Discussionmentioning

confidence: 99%

One-Sided Headache Is a Symptom Suggesting Aneurysmal Lesion in Patients with Isolated Abducens Nerve Palsy

Oku

Miyachi

Ikeda

2016

An isolated unilateral abducens nerve palsy or headache alone usually yields negative findings on neuroimages. The authors report an individual with right abducens nerve palsy who developed a sudden, persistent headache on the right side. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) revealed a giant aneurysm of the cavernous carotid artery that was located along the course of the right abducens nerve. The findings in this case of isolated abducens nerve palsy suggest that headaches should be considered as important signs for intracranial aneurysmal lesions. ARTICLE HISTORY