We classify TNPs as either nonisolated or isolated. Is the TNP Isolated or Nonisolated? Can the TNP Be Localized? In this section, we discuss the localization of TNPs associated with other neurologic signs (nonisolated TNPs) and TNPs without other associated neurologic or neuro-ophthalmologic deficits (isolated TNPs) (Lee, 1999). Partial TNPs may cause (in combination or isolation) variable ptosis variable paresis of eye adduction, elevation, and depression and variable pupillary involvement. The oculomotor nerve (third cranial nerve) supplies four extraocular muscles (medial, superior and inferior recti, and inferior oblique) as well as the levator of the lid, and contains parasympathetic fibers that supply the sphincter of the pupil and the ciliary body A complete peripheral third nerve palsy (TNP) thus causes ptosis, a fixed and dilated pupil, and a down (hypotropic) and out (exotropic) resting eye position. Skoglund TS, Nellgard B (2005) Long-time outcome after transient transtentorial herniation in patients with traumatic brain injury.What Are the Clinical Features of a Third Cranial Nerve Palsy? Rucker CW, Keefe WP, Kernohan JW (1959) Pathogenesis of paralysis of the third cranial nerve. Park UC, Kim SJ, Hwang JM, Yu YS (2008) Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy. Mushkudiani NA, Engel DC, Steyerberg EW, Butcher I, Lu J, Marmarou A, Slieker F, McHugh GS, Murray GD, Maas AI (2007) Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. Marmarou A, Lu J, Butcher I, McHugh GS, Murray GD, Steyerberg EW, Mushkudiani NA, Choi S, Maas AI (2007) Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. Kernohan JW, Woltman HW (1929) Incisura of the crus due to contralateral brain tumour. Greaves D (1978) Sir Jonathan Hutchinson. J Neurol Neurosurg Psychiatry 71:175–181Ĭollier J (1904) The false localizing signs of intracranial tumour. Injury 40:28–32Ĭlusmann H, Schaller C, Schramm J (2001) Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome. Jpn J Ophthalmol 52:32–35Ĭhaudhuri K, Malham GM, Rosenfeld JV (2009) Survival of trauma patients with coma and bilateral fixed dilated pupils. KeywordsĪkagi T, Miyamoto K, Kashii S, Yoshimura N (2008) Cause and prognosis of neurologically isolated third, fourth, or sixth cranial nerve dysfunction in cases of oculomotor palsy. A FDP is a grave prognostic sign following TBI commonly resulting in long term ophthalmological sequelae however, a favourable outcome is still attainable. Most patients with bilateral FDP did not survive (88%) however, of those who did survive, none was left in a persistent vegetative state or with any ophthalmological sequelae. Of those patients who survived an FDP, 72% were left with some form of ophthalmological deficit. In 34% of cases CT demonstrated a lateralising condition ipsilateral to the side of the FDP and in 9% cases the FDP was contralateral to the side of the CT abnormality. In patients presenting with a unilateral FDP, the CT-defined condition was most commonly diffuse brain injury (49%) with no obvious lateralising condition. In approximately three-quarters of cases, some form of road traffic incident was the mechanism of injury. The objectives of this study were to determine the underlying condition responsible, the natural history of recovery of third nerve palsy and the ultimate clinical outcome in 60 patients admitted to a regional neurosurgical centre with a diagnosis of TBI and unilateral or bilateral fixed, dilated pupils (FDP). Pupillary abnormalities are commonly seen in patients presenting with severe traumatic brain injury (TBI).
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