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Recurrent isolated oculomotor nerve palsy after radiation of a mesencephalic metastasis. Case report and mini review.

Grabau O, Leonhardi J, Reimers CD - Front Neurol (2014)

Bottom Line: Recurrent oculomotor nerve palsies are extremely rare clinical conditions.The episodic palsies were probably caused by an ipsilateral mesencephalic metastasis of a breast carcinoma and occurred after successful brain radiation therapy.While the pathogenic mechanism remains unclear, the recurrent sudden onset and disappearance of the palsies and their decreasing frequency after antiepileptic treatment suggest the occurrence of epilepsy-like brainstem seizures.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Zentralklinik Bad Berka , Bad Berka , Germany.

ABSTRACT

Introduction: Recurrent oculomotor nerve palsies are extremely rare clinical conditions.

Case report: Here, we report on a unique case of a short-lasting recurrent unilateral incomplete external and complete internal oculomotor nerve palsy. The episodic palsies were probably caused by an ipsilateral mesencephalic metastasis of a breast carcinoma and occurred after successful brain radiation therapy.

Discussion: While the pathogenic mechanism remains unclear, the recurrent sudden onset and disappearance of the palsies and their decreasing frequency after antiepileptic treatment suggest the occurrence of epilepsy-like brainstem seizures. A review of case reports of spontaneous reversible oculomotor nerve palsies is presented.

No MeSH data available.


Related in: MedlinePlus

Equal size pupils without blepharoptosis (top) in the interval between attacks of left-sided blepharoptosis, and maximally enlarged pupil during an attack (bottom, arrow) (with written permission of the patient).
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Figure 2: Equal size pupils without blepharoptosis (top) in the interval between attacks of left-sided blepharoptosis, and maximally enlarged pupil during an attack (bottom, arrow) (with written permission of the patient).

Mentions: The patient was hospitalized into the neurological department because of newly occurring headaches and temporarily reduced alertness. The initial neurological examination revealed diminished consciousness, slight neck stiffness, only small pupillary reaction of the right pupil and a large, unreactive, and maximally enlarged left pupil, a quadriparesis with only weak movements of the right arm, loss of tendon reflexes of the lower extremities, and a left-sided positive Babinski sign. During her stay, an episode of sudden complete loss of consciousness accompanied by left-sided blepharoptosis and mydriasis, and bradycardia occurred. Before and after it no weakness of the extraocular muscles, ptosis, unreactivity of the left pupil, or anisocoria were present (Figure 2). While native and gadolinium-enhanced MRI performed on the same day demonstrated an acute ischemia in the right frontal lobe, the cerebral metastases were considerably less obvious after interim brain radiation therapy (Figure 1). Assuming an atypical epilepsy-like brainstem seizure, she was treated with levetiracetam 1.5 g b.i.d. During the subsequent days, several episodes of sudden maximal mydriasis of the left pupil were observed that were occasionally accompanied by complete blepharoptosis that spontaneously disappeared after several minutes (Figure 2). During these episodes, her consciousness occasionally diminished further. Due to diminished consciousness, the oculomotor motility could not be examined properly during the attacks. In the intervals, no weakness of the extra- and intraocular muscles on either side was evident. Three electroencephalograms showed slight to pronounced general slowing down with or without few focal epileptic discharges. Lacosamide 200 mg b.i.d. was added resulting in a lower frequency of these ophthalmoplegic episodes. Furthermore, the patient became alert and orientated. However, she died 20 days after admission. An autopsy was not performed.


Recurrent isolated oculomotor nerve palsy after radiation of a mesencephalic metastasis. Case report and mini review.

Grabau O, Leonhardi J, Reimers CD - Front Neurol (2014)

Equal size pupils without blepharoptosis (top) in the interval between attacks of left-sided blepharoptosis, and maximally enlarged pupil during an attack (bottom, arrow) (with written permission of the patient).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4109435&req=5

Figure 2: Equal size pupils without blepharoptosis (top) in the interval between attacks of left-sided blepharoptosis, and maximally enlarged pupil during an attack (bottom, arrow) (with written permission of the patient).
Mentions: The patient was hospitalized into the neurological department because of newly occurring headaches and temporarily reduced alertness. The initial neurological examination revealed diminished consciousness, slight neck stiffness, only small pupillary reaction of the right pupil and a large, unreactive, and maximally enlarged left pupil, a quadriparesis with only weak movements of the right arm, loss of tendon reflexes of the lower extremities, and a left-sided positive Babinski sign. During her stay, an episode of sudden complete loss of consciousness accompanied by left-sided blepharoptosis and mydriasis, and bradycardia occurred. Before and after it no weakness of the extraocular muscles, ptosis, unreactivity of the left pupil, or anisocoria were present (Figure 2). While native and gadolinium-enhanced MRI performed on the same day demonstrated an acute ischemia in the right frontal lobe, the cerebral metastases were considerably less obvious after interim brain radiation therapy (Figure 1). Assuming an atypical epilepsy-like brainstem seizure, she was treated with levetiracetam 1.5 g b.i.d. During the subsequent days, several episodes of sudden maximal mydriasis of the left pupil were observed that were occasionally accompanied by complete blepharoptosis that spontaneously disappeared after several minutes (Figure 2). During these episodes, her consciousness occasionally diminished further. Due to diminished consciousness, the oculomotor motility could not be examined properly during the attacks. In the intervals, no weakness of the extra- and intraocular muscles on either side was evident. Three electroencephalograms showed slight to pronounced general slowing down with or without few focal epileptic discharges. Lacosamide 200 mg b.i.d. was added resulting in a lower frequency of these ophthalmoplegic episodes. Furthermore, the patient became alert and orientated. However, she died 20 days after admission. An autopsy was not performed.

Bottom Line: Recurrent oculomotor nerve palsies are extremely rare clinical conditions.The episodic palsies were probably caused by an ipsilateral mesencephalic metastasis of a breast carcinoma and occurred after successful brain radiation therapy.While the pathogenic mechanism remains unclear, the recurrent sudden onset and disappearance of the palsies and their decreasing frequency after antiepileptic treatment suggest the occurrence of epilepsy-like brainstem seizures.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Zentralklinik Bad Berka , Bad Berka , Germany.

ABSTRACT

Introduction: Recurrent oculomotor nerve palsies are extremely rare clinical conditions.

Case report: Here, we report on a unique case of a short-lasting recurrent unilateral incomplete external and complete internal oculomotor nerve palsy. The episodic palsies were probably caused by an ipsilateral mesencephalic metastasis of a breast carcinoma and occurred after successful brain radiation therapy.

Discussion: While the pathogenic mechanism remains unclear, the recurrent sudden onset and disappearance of the palsies and their decreasing frequency after antiepileptic treatment suggest the occurrence of epilepsy-like brainstem seizures. A review of case reports of spontaneous reversible oculomotor nerve palsies is presented.

No MeSH data available.


Related in: MedlinePlus