Isolated Central 4th Nerve Palsy

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Identifier central_4th_NP
Title Isolated Central 4th Nerve Palsy
Alternative Title Video 4.31 A ‘central' 4th nerve palsy due to midbrain hemorrhage from Neuro-Ophthalmology and Neuro-Otology Textbook
Creator Kemar Green, DO; Daniel R. Gold, DO
Affiliation (KG) Department of Neurology, Michigan State University, East Lansing, Michigan; (DRG) Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, and Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
Subject Fourth Nerve Palsy; OMS Midbrain
Description ๐—ข๐—ฟ๐—ถ๐—ด๐—ถ๐—ป๐—ฎ๐—น ๐——๐—ฒ๐˜€๐—ฐ๐—ฟ๐—ถ๐—ฝ๐˜๐—ถ๐—ผ๐—ป: This is a 40-year-old man with a right hypertropia that worsened in left and down gaze in addition to right head tilt, and improved in left head tilt. There was subjective excyclotorsion OD with double Maddox rod testing. This was consistent with a right 4th nerve palsy. He had a known left midbrain cavernoma which had bled several years prior to this evaluation making the localization of his 4th nerve palsy "central". Given the proximity of the left 4th nucleus and its fascicle to the left medial longitudinal fasciculus (MLF) and oculosympathetic tract, when a left internuclear ophthalmoplegia (INO) and/or left Horner's syndrome, respectively, is seen with a right (CONTRALATERAL) 4th nerve palsy, a "central" 4th is strongly suggested relating to the decussating course of the 4th nerve (see https://collections.lib.utah.edu/details?id=1260008). However, an isolated 4th nerve palsy can also be central and related to nuclear and/or fascicular injury, as in this case. ๐—ก๐—ฒ๐˜‚๐—ฟ๐—ผ-๐—ผ๐—ฝ๐—ต๐˜๐—ต๐—ฎ๐—น๐—บ๐—ผ๐—น๐—ผ๐—ด๐˜† ๐—ฎ๐—ป๐—ฑ ๐—ก๐—ฒ๐˜‚๐—ฟ๐—ผ-๐—ผ๐˜๐—ผ๐—น๐—ผ๐—ด๐˜† ๐—ง๐—ฒ๐˜…๐˜๐—ฏ๐—ผ๐—ผ๐—ธ ๐—Ÿ๐—ฒ๐—ด๐—ฒ๐—ป๐—ฑ: This patient had a right hypertropia that worsened in left and down gaze in addition to right head tilt, and improved in left head tilt. There was subjective excyclotorsion OD with double Maddox rod testing. This was consistent with a right 4th nerve palsy. He had experienced a left midbrain hemorrhage which had bled several years prior to this evaluation making the localization of his 4th nerve palsy "central". Given the proximity of the left 4th nucleus and its fascicle to the left medial longitudinal fasciculus (MLF) and oculosympathetic tract, when a left internuclear ophthalmoplegia (INO) and/or left Horner's syndrome, respectively, is seen with a right (CONTRALATERAL) 4th nerve palsy, a โ€˜central' 4th NP is strongly suggested relating to the decussating course of the 4th nerve. However, an isolated 4th NP can also be central and related to nuclear and/or fascicular injury, and will be contralesional as in this case. (Video and legend created with the assistance of Dr. Kemar Green) https://collections. lib.utah.edu/ark:/87278/s6hf1tbf
Date 2018-02
Language eng
Format video/mp4
Type Image/MovingImage
Collection Neuro-Ophthalmology Virtual Education Library: Dan Gold Neuro-Ophthalmology Collection: https://novel.utah.edu/Gold/
Publisher North American Neuro-Ophthalmology Society
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-5890
Rights Management Copyright 2016. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
ARK ark:/87278/s6hf1tbf
Setname ehsl_novel_gold
ID 1295179
Reference URL https://collections.lib.utah.edu/ark:/87278/s6hf1tbf
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