Fourth nerve palsy: Difference between revisions
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==Background== | ==Background== | ||
*Also called | [[File:Capture2.PNG|thumbnail|Right eye]] | ||
[[File:Extraocular muscle actions and innervation.png|thumb|Eye movements by extra-ocular muscles and cranial nerve innervation]] | |||
*Also called CN IV or trochlear nerve palsy | |||
*Trochlea innervates superior oblique muscle | *Trochlea innervates superior oblique muscle | ||
**Intorts, depresses and abducts the globe | **Intorts, depresses and abducts the globe | ||
*Trochlear nerve palsy causes an inability to move the eye in inward rotation, downward, and laterally. <ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> | *Trochlear nerve palsy causes an inability to move the eye in inward rotation, downward, and laterally. <ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> | ||
*Most common cause of vertical diplopia <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> | *Most common cause of vertical [[diplopia]] <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> | ||
===Etiology=== | ===Etiology=== | ||
*[[Head trauma]] <ref name="book">Disorders of Ocular Movement and Pupillary Function In: Adams and Victor's Principles of Neurology. 10th ed. Accessed on AccessMedicine.com on 8/29/2015. Chapter 14 </ref> | *[[Head trauma]] <ref name="book">Disorders of Ocular Movement and Pupillary Function In: Adams and Victor's Principles of Neurology. 10th ed. Accessed on AccessMedicine.com on 8/29/2015. Chapter 14 </ref> | ||
*Mechanisms that increase intraocular pressure | *Mechanisms that increase intraocular pressure | ||
**Practically never | **Practically never caused by aneurysm | ||
*[[Herpes zoster]] | *[[Herpes zoster]] ophthalmicus | ||
*[[Meningitis]] | *[[Meningitis]] | ||
*Diabetic neuropathy | *Diabetic neuropathy | ||
*[[Lupus]]/ | *[[Lupus]]/[[Sjögren]] syndrome | ||
==Clinical Features== | ==Clinical Features== | ||
*Vertical, torsional, or oblique diplopia. | *Vertical, torsional, or oblique [[diplopia]]. | ||
**Worse on downward gaze and gaze away from affected muscle <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> | **Worse on downward gaze and gaze away from affected muscle <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> | ||
*Head-tilt | *Head-tilt | ||
**Tilt typically away from affected side (~70%) to overcome inward rotation of affected eye to create wider separation of images. Can be paradoxical, where patient tilts head toward affected side (~3%) <ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> <ref name="brazis">Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14</ref> | **Tilt typically away from affected side (~70%) to overcome inward rotation of affected eye to create wider separation of images. Can be paradoxical, where patient tilts head toward affected side (~3%) <ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> <ref name="brazis">Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14</ref> | ||
**Bielschowsky phenomenon - head tilt to affected side reveals inability to intort, diplopia | **Bielschowsky phenomenon - head tilt to affected side reveals inability to intort, diplopia | ||
[[File:trochlear nerve palsy.jpg|thumbnail]] | [[File:trochlear nerve palsy.jpg|thumbnail]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*''Increased intracranial pressure (ICP)'': [[Pseudotumor cerebri]] | *''Increased intracranial pressure (ICP)'': [[Pseudotumor cerebri]] | ||
*''Vascular'': [[Stroke (main) | Stroke]], [[subarachnoid hemorrhage]], aneurysm (extremely rare), microvasculopathy | *''Vascular'': [[Stroke (main) | Stroke]], [[subarachnoid hemorrhage]], aneurysm (extremely rare), microvasculopathy from diabetes, atherosclerosis or hypertension<ref name="brazis">Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14</ref> | ||
*''Neoplastic'': Tumor in the subarachnoid space | *''Neoplastic'': [[Intracranial mass|Tumor]] in the subarachnoid space | ||
*''Degenerative/deficiency'': Vitamin | *''Degenerative/deficiency'': [[Vitamin B12 deficiency]], [[Wernicke-Korsakoff syndrome]] | ||
*''Idiopathic'': Most common cause of acquired trochlear nerve palsy. | *''Idiopathic'': Most common cause of acquired trochlear nerve palsy. | ||
*''Infection'': [[Meningitis]], [[herpes zoster]] | *''Infection'': [[Meningitis]], [[herpes zoster]] | ||
*''Congenital'': | *''Congenital'': Dysgenesis of trochlear nerve nucleus or abnormal peripheral nerve | ||
*''Autoimmune'': [[Myasthenia gravis]], [[multiple sclerosis]], [[systemic lupus erythematosus]], [[giant cell arteritis]], [[ | *''Autoimmune'': [[Myasthenia gravis]], [[multiple sclerosis]], [[systemic lupus erythematosus]], [[giant cell arteritis]], [[Sjögren]] | ||
*''Trauma'': Its long course makes it susceptible to traumatic injury. [[Head trauma (adult)]] is the second most common cause. Is generally severe with loss of consciousness. Consider underlying structural abnormalities if results after minor trauma. | *''Trauma'': Its long course makes it susceptible to traumatic injury. [[Head trauma (adult)]] is the second most common cause. Is generally severe with loss of consciousness. Consider underlying structural abnormalities if results after minor trauma. | ||
*''Endocrine'': Thyroid ophthalmopathy <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> <ref name="brazis">Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14</ref> | *''Endocrine'': [[Thyroid]] ophthalmopathy <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> <ref name="brazis">Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14</ref> | ||
*[[Third nerve palsy]] | *[[Third nerve palsy]] | ||
*[[Abducens nerve palsy]] | *[[Abducens nerve palsy]] | ||
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===Labs and Tests=== | ===Labs and Tests=== | ||
*+/- POC glucose, CBC, and other labs depending on suspected diagnosis | *+/- POC glucose, CBC, and other labs depending on suspected diagnosis | ||
*+/- LP after negative neuroimaging if suspect subarachnoid hemorrhage or meningitis. | *+/- [[LP]] after negative neuroimaging if suspect [[subarachnoid hemorrhage]] or [[meningitis]]. | ||
===Imaging=== | ===Imaging=== | ||
*CT | *[[Head CT]] if traumatic, suspect stroke, or subarachnoid hemorrhage (rare). | ||
*MRI is study of choice, although there no increased yield from MRI vs CT scan. <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> <ref name="brazis">Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14</ref> | *[[brain MRI|MRI]] is study of choice, although there no increased yield from MRI vs CT scan. <ref name="medscape">Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015</ref> <ref name="brazis">Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14</ref> | ||
==Management== | ==Management== | ||
*Address | *Address underlying acute pathology | ||
*May require surgical correction | *May require surgical correction | ||
*+/- Neurology consult | *+/- Neurology consult | ||
==Disposition== | ==Disposition/Follow-up== | ||
*'''Vasculopathic''': Observation for improvement over 6-8 weeks. Often resolve spontaneously in 4-6 months. | *'''Vasculopathic''': Observation for improvement over 6-8 weeks. Often resolve spontaneously in 4-6 months. | ||
*'''Traumatic''': Observation for improvement over 6-8 weeks. Often resolves spontaneously. If progressing or lack of improvement – neuroimaging with MRI | *'''Traumatic''': Observation for improvement over 6-8 weeks. Often resolves spontaneously. If progressing or lack of improvement – neuroimaging with MRI | ||
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==External Links== | ==External Links== | ||
[http://emedicine.medscape.com/article/1200187-overview Medscape: Trochlear Nerve Palsy] | *[http://emedicine.medscape.com/article/1200187-overview Medscape: Trochlear Nerve Palsy] | ||
==References== | ==References== | ||
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[[Category:Ophthalmology]] | [[Category:Ophthalmology]] | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Symptoms]] | |||
Latest revision as of 16:21, 26 September 2020
Background
- Also called CN IV or trochlear nerve palsy
- Trochlea innervates superior oblique muscle
- Intorts, depresses and abducts the globe
- Trochlear nerve palsy causes an inability to move the eye in inward rotation, downward, and laterally. [1]
- Most common cause of vertical diplopia [2]
Etiology
- Head trauma [3]
- Mechanisms that increase intraocular pressure
- Practically never caused by aneurysm
- Herpes zoster ophthalmicus
- Meningitis
- Diabetic neuropathy
- Lupus/Sjögren syndrome
Clinical Features
- Vertical, torsional, or oblique diplopia.
- Worse on downward gaze and gaze away from affected muscle [2]
- Head-tilt
Differential Diagnosis
- Increased intracranial pressure (ICP): Pseudotumor cerebri
- Vascular: Stroke, subarachnoid hemorrhage, aneurysm (extremely rare), microvasculopathy from diabetes, atherosclerosis or hypertension[4]
- Neoplastic: Tumor in the subarachnoid space
- Degenerative/deficiency: Vitamin B12 deficiency, Wernicke-Korsakoff syndrome
- Idiopathic: Most common cause of acquired trochlear nerve palsy.
- Infection: Meningitis, herpes zoster
- Congenital: Dysgenesis of trochlear nerve nucleus or abnormal peripheral nerve
- Autoimmune: Myasthenia gravis, multiple sclerosis, systemic lupus erythematosus, giant cell arteritis, Sjögren
- Trauma: Its long course makes it susceptible to traumatic injury. Head trauma (adult) is the second most common cause. Is generally severe with loss of consciousness. Consider underlying structural abnormalities if results after minor trauma.
- Endocrine: Thyroid ophthalmopathy [2] [4]
- Third nerve palsy
- Abducens nerve palsy
Evaluation
Labs and Tests
- +/- POC glucose, CBC, and other labs depending on suspected diagnosis
- +/- LP after negative neuroimaging if suspect subarachnoid hemorrhage or meningitis.
Imaging
- Head CT if traumatic, suspect stroke, or subarachnoid hemorrhage (rare).
- MRI is study of choice, although there no increased yield from MRI vs CT scan. [2] [4]
Management
- Address underlying acute pathology
- May require surgical correction
- +/- Neurology consult
Disposition/Follow-up
- Vasculopathic: Observation for improvement over 6-8 weeks. Often resolve spontaneously in 4-6 months.
- Traumatic: Observation for improvement over 6-8 weeks. Often resolves spontaneously. If progressing or lack of improvement – neuroimaging with MRI
- Isolated, idiopathic cases very rarely have an underlying etiology after prolonged follow-up, and most resolve spontaneously in weeks to months. If no improvement in 2 months, consider neuroimaging. [4]
See Also
External Links
References
- ↑ 1.0 1.1 Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013
- ↑ 2.0 2.1 2.2 2.3 Sheik Z. Trochlear Nerve Palsy Treatment and Management on emedicine.medscape.com/article/1200187 Accessed on 8/29/2015
- ↑ Disorders of Ocular Movement and Pupillary Function In: Adams and Victor's Principles of Neurology. 10th ed. Accessed on AccessMedicine.com on 8/29/2015. Chapter 14
- ↑ 4.0 4.1 4.2 4.3 4.4 Brazis, PW. Isolated palsies of cranial nerves III, IV, and VI. Seminars in neurology. 2009 Feb. 29(1):14