NEUROANATOMY

CASE STUDY
 CASE:
A 35 year-old male is somnolent because of
head injury, but is arousable. His left eye is turned
down and out and does not turn on command
although the other eye moves on command.
When the patient attempts to look to the right
and down, the left eye intorts strongly, but remains
turned down and out.
His left pupil is dilated and fixed (non-reactive)
to light or accommodation. No eye drops were used.
The right pupil shows a direct consensual response
to light and reacts normally in accomodation
Where is the lesion?
History
Pertinent Positive:

- Somnolent
- left eye is turned down and out and does
not turn on command
- left eye intorts strongly, but remains
turned down and out
- left pupil is dilated and fixed (non-
reactive) to light or accommodation.
History
Pertinent Negative:

- Arousable
- right eye moves on command
- right pupil shows a direct consensual
response to light and reacts normally in
accomodation
Physical Exam
 Pupillary Reflex
Tested in two main ways:
• By moving a finger towards a person's face to induce
accommodation, as well as them going cross-eyed, their pupils
should constrict.
• Shining a light into their eyes should also make their pupils
constrict. Both pupils should constrict at the same time,
independent of what eye the light is actually shone on.

 Eye muscle Test

Is performed to evaluate any weakness, or other defect in the
extraocular muscles which results in uncontrolled eye movements.
The test involves moving the eyes in six different directions in
space to evaluate the proper functioning of the extraocular muscles
of the eyes.
Definition of Terms
Somnolence - An inclination to sleep; drowsiness
Intorts - turns a part medialward

Accommodation - the process by which the curvature

of the lens is increased
 Definition of Terms
Hematoma - A localized mass of extravasated blood that is relatively or
completely confined within an organ or tissue, a space, or a potential
space; the blood is usually clotted, and, depending on how long it has been
there, may manifest various degrees of organization and decolorization

Palsy - Paralysis or paresis.

Ptosis – drooping of the eyelid

Light Reflex -
When light is directed into one eye, the pupil constricts
(pupillary light reflex).
The pupil of the other eye also constricts
(consensual light reflex).
 Oculomotor Nerve (CN III)
Occulomotor nerve has two (2) motor nuclei:
1. The main motor nucleus
2. The accessory parasympathetic nucleus

 The former supplies the extrinsic muscles of

the eye except the Superior oblique and Lateral
rectus muscles.
 The later supplies the constrictor pupillae of
the iris and the ciliary muscles and receives
corticonuclear fibers for accomodation reflex and
pretectal fibers for direct and consensual light reflex
 Oculomotor Nerve (CN III)
Course of the Oculomotor Nerve

 emerges on the anterior surface of the midbrain

 Passes between the posterior cerebral and superior

cerebellar arteries

 Continues into middle cranial fossa in the lateral wall

of the cavernous sinus

 Divides into a superior and inferior ramus, which

enter the orbital cavity through the superior orbital
fissure
ac
ac
DISCUSSION:

Clinical significance of the Midbrain

The midbrain forms the upper end of the narrow stalk of the brain or
brainstem. As it ascends out of the posterior cranial fossa through
relatively small rigid opening in the tentorium cerebelli, it is vulnerable to
traumatic injury.
It possesses two important cranial nerve nuclei (occulomotor & trochlear),
reflex centers (the colliculi), the red nucleus and the substantia nigra,
which greatly influence motor function, and it serves as a conduit for many
important ascending and descending tracts.
As in other parts of the brainstem, it is a site for tumors, hemorrhage or
infarcts that will produce a wide variety of signs and symptoms.
DISCUSSION:

Clinical significance of the Midbrain

The Superior Colliculus, a large nucleus of gray matter that lies beneath the
corresponding surface elevation, forms part of the visual reflexes.

It is connected to the lateral geniculate body by the superior brachium.

It receives afferent fibers from the optic nerve, the visual cortex, and the
spinotectal tract.

The efferent fibers from the tectospinal and the tectobulbar tracts, which are
responsible for the reflex movements of the eyes, head, and neck in
response to visual stimuli.
DISCUSSION:

Clinical significance of the Midbrain

The afferent pathway for the light reflex ends in the pretectal nucleus. This is a
small group of Neurons situated close to the lateral part of the Superior
Colliculus.

After relaying in the pretectal nucleus,the fibers pass to the parasympathetic

nucleus of the occulomotor nerve (Edinger- Westphal nucleus).
The emerging fibers then pass to the occulomotor nerve.

On the other hand the Inferior Colliculus forms part of the auditory pathway.
Differential Diagnosis

[Link]’s Syndrome

[Link] syndrome

[Link] Nerve Palsy

 Oculomotor nerve palsy
Background

• Extraocular muscle paralysis resulting from destructive lesions in

one or all of the cranial nerves (III,IV,VI) results in failure of one
or both eyes to rotate in concert with the other eye.
• The primary symptom is diplopia from misalignment of the visual
axes, and the pattern of image separation is the key to diagnosing
which particular cranial nerve (and extraocular muscle) is involved.
• With unilateral third cranial nerve palsy, the involved eye usually
is deviated down and out (infraducted, abducted), and there is
ptosis.
• In addition, pupillary dilatation can cause symptomatic glare in
bright light, and paralysis of accommodation causes blurred vision
for near objects.
Oculomotor nerve palsy
Causes

[Link] disorders such as diabetes, heart disease,

atherosclerosis and aneurysm, particularly of the posterior
communicating artery.
2. Space occupying lesions or tumours, both malignant and non-
malignant.
3. Inflammation and Infection
4. Trauma
5. Demyelinating disease (Multiple sclerosis)
6. Auto-immune disorders such as AIDS or Myasthenia gravis
7. Post operatively as a complication of neurosurgery.
PATHOPHYSIOLOGY
DILATED PUPIL
The ipsilateral oculomotor nerve
IMPRESSION

Isolated Left Oculomotor Nerve

Palsy Due to Head Injury
DISCUSSION:
Oculomotor nerve palsy following closed head trauma may
be caused by direct injury of the nerve or by indirect
compression of the nerve by an expanding hematoma.

Direct traumatic oculomotor nerve palsy is uncommon and is

usually associated with subarachnoid hemorrhage, skull fracture,
aneurysm, carotid-cavernous fistula or midbrain lesion
DISCUSSION:
Therefore, involvement of the left occulomotor nucleus will
produce ipsilateral paralysis of the following muscles:

Levator palpebrae superioris

Superior rectus
Inferior rectus
Medial rectus
Inferior oblique

Thus, the patient’s left eye intorts strongly but remains turned
down and out when he attempts to look to the right and down.
DISCUSSION:
In addition, axons of the left accessory parasympathetic
nucleus (Edinger-Westphal nucleus) which are
preganglionic accompany the other occulomotor fibers to
the orbit. There, they synapse in the olivary ganglion and
postganglionic fibers through the ciliary nerves to the
constrictor pupillae of the iris and ciliary muscles. The
accessory parasympathetic nucleus receives
corticonuclear fibers for accommodation reflex.

Paralysis of this nucleus will result of left occulomotor

nerve palsy causes absence of light and accommodation
reflexes on the left side of the eye.
DISCUSSION:
The arrangement for other muscles in the third nerve fascicle in
ventral mesencephalon from lateral to medial include inferior
oblique, superior rectus, medial rectus, levator palpebrae and
inferior rectus.
This arrangement can also explain the occurrence of paresis of
individual extraocular muscles alone or in combination or even
a unilateral fixed and dilated pupil without other neurological
dysfunction.
Nuclear third nerve involvement in the midbrain results in
bilateral superior rectus paresis and ptosis in addition to
ipsilateral TNP; however a fascicular involvement does not
lead to any symptom/sign on the contralateral side.
DISCUSSION:

In some cases third nerve injury has occurred even with

minor head injury due to mechanical stress. Disturbance
in blood supply or detrimental biochemical effects arising
from head injury can also lead to nerve damage. Direct
damage to third nerve nucleus or nerve origin inside
midbrain is one of the rare causes of third nerve injury.
The nerve function may be expected to improve as the
hematoma resolves but complete recovery is rare.
DISCUSSION:
The prognosis of traumatic oculomotor palsy is usually
poor. Generally speaking, patients experience more rapid
and complete recovery of ptosis than of extraocular
movements, while pupillary size and light reflex show the
least degree of recovery.

Further case collections with modern imaging studies are

needed to clarify the mechanisms and clinical
characteristics associated with this phenomenon.
IMAGING STUDIES
MRI/MRA
- MRI is a more sensitive imaging technique than
CT scan for picking out a small intraparenchymal
brainstem lesion, such as infarction, small abscess,
or tumor.

CT scan
- CT scan is better than MRI for demonstrating
calcification within lesions, as may be found in
certain tumors and in large aneurysms.
PROCEDURES:
Lumbar puncture
– The main purpose of lumbar puncture is to demonstrate the presence of
blood in cerebrospinal fluid, an inflammatory reaction, neoplastic
infiltration, or infection.
– Bloody spinal fluid with oculomotor nerve palsy usually results from
rupture of a posterior communicating artery berry aneurysm.

Cerebral angiography
– Conventional angiography is the definitive test for berry aneurysm in all
intracranial locations.
– Angiography is indicated in a patient with third cranial nerve palsy and
dilated, light-fixed pupil. It may be indicated in a patient younger than
55-60 years, especially without a history of long-standing diabetes,
hypertension, or both.
RECOMMENDATION:
Brain computerized tomography (CT) is recommended in
acutely traumatized patients with the third nerve palsy to
rapidly evaluate blood, bone, and midbrain structures.

Cerebral angiography is indicated when a vascular

anomaly is the possible etiology. A complete imaging
investigation for traumatic oculomotor nerve palsy should
include brain magnetic resonance imaging (MRI), because
CT may fail to detect midbrain damage and oculomotor
nerve root avulsion.