Skip to main content
Advertisement

Main menu

  • Home
  • Content
    • Current Issue
    • Publication Preview--Ahead of Print
    • Past Issue Archive
    • Case of the Week Archive
    • Classic Case Archive
    • Case of the Month Archive
  • For Authors
  • About Us
    • About AJNR
    • Editors
    • American Society of Neuroradiology
  • Submit a Manuscript
  • Podcasts
    • Subscribe on iTunes
    • Subscribe on Stitcher
  • More
    • Subscribers
    • Permissions
    • Advertisers
    • Alerts
    • Feedback
  • Other Publications
    • ajnr

User menu

  • Subscribe
  • Alerts
  • Log in

Search

  • Advanced search
American Journal of Neuroradiology
American Journal of Neuroradiology

American Journal of Neuroradiology

  • Subscribe
  • Alerts
  • Log in

Advanced Search

  • Home
  • Content
    • Current Issue
    • Publication Preview--Ahead of Print
    • Past Issue Archive
    • Case of the Week Archive
    • Classic Case Archive
    • Case of the Month Archive
  • For Authors
  • About Us
    • About AJNR
    • Editors
    • American Society of Neuroradiology
  • Submit a Manuscript
  • Podcasts
    • Subscribe on iTunes
    • Subscribe on Stitcher
  • More
    • Subscribers
    • Permissions
    • Advertisers
    • Alerts
    • Feedback
  • Follow AJNR on Twitter
  • Visit AJNR on Facebook
  • Follow AJNR on Instagram
  • Join AJNR on LinkedIn
  • RSS Feeds
Case ReportHead and Neck

MR Imaging Features of Acquired Brown Syndrome

S. Currie and T. Goddard
American Journal of Neuroradiology October 2009, 30 (9) 1778-1779; DOI: https://doi.org/10.3174/ajnr.A1591
S. Currie
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
T. Goddard
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • References
  • PDF
Loading

Abstract

SUMMARY: Brown syndrome describes the inability of a patient to perform an upward gaze while the eye is adducted due to an abnormality of the superior oblique tendon sheath complex. Use of CT in diagnosing the condition has been reported; however, the use of MR imaging has not. We describe a unique case of Brown syndrome in which the initial CT findings were normal, but MR imaging revealed the abnormality. Key imaging features are illustrated.

Brown syndrome is characterized by the inability to gaze upward beyond the horizontal level while adducting the eye due to an abnormality of the superior oblique tendon sheath complex.1

The course of the superior oblique tendon can be demonstrated on axial CT images. CT is unable to resolve fully the different components of the trochlea area; however, the combined structures are discernible (Fig 1). Axial MR imaging offers even less resolution, and both coronal CT and MR imaging allow visualization of only portions of the muscle belly (Fig 2).

Fig 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 1.

Axial CT scan of the orbits demonstrates the course of the superior oblique muscle/tendon. The muscle extends anteriorly to the superomedial corner of the orbit (white arrowhead). Here it reaches the trochlea (black arrow), a fibrocartilaginous structure lying deep within the orbital fascia. Just before reaching the trochlea, the muscle becomes tendinous, and while passing through it, the tendon is compressed into a fibrous cord. Exiting the trochlea, the tendon runs inferiorly, posteriorly, and laterally (white arrow) to insert into the posterolateral portion of the sclera.

Fig 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 2.

Coronal T1-weighted MR image of the orbits demonstrates the extraocular muscles in relation to the optic nerve: superior rectus (s), lateral rectus (l), medial rectus (m), inferior rectus (i), superior oblique (so), and optic nerve (on).

CT characteristics of the condition have been described and include thickening of the tendon, often the reflected portion following passage through the trochlea.2 This feature was not discernible on the CT performed on our patient. Conversely, MR imaging confirmed the diagnosis. This unique case describes the salient features of acquired Brown syndrome on MR imaging and highlights the use of MR imaging as a diagnostic tool when CT findings are negative.

Case Report

A 46-year-old woman with known systemiclupus erythematosis (SLE) presented acutely with a 2-week history of severe headache associated with vertical double vision, particularly in an upward gaze to the left. She experienced tenderness to palpation over the right trochlea region.

Laboratory values for blood tests, including full blood count, urea and electrolytes, plasma glucose, immunoglobulins, serum complement, antineutrophil cytoplasmic antibody, and cardiolipin antibodies were normal. The antinuclear antibody-2 test was positive, but retrospective review of her blood results showed that this had been positive during a 4-year period before this presentation and was attributable to SLE.

CT head imaging findings with and without contrast were normal (Fig 3). MR imaging of the brain showed no intracranial abnormality. However, the right superior oblique tendon was abnormally thickened on T1-weighted imaging (Fig 4) and of abnormally high signal intensity on T2-weighted fat-saturated imaging (Fig 5) and demonstrated mild enhancement after administration of gadolinium (Fig 6).

Fig 3.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 3.

Axial CT scan of the patient's orbits shows no discernable difference between the appearances of both superior oblique tendons (white arrows).

Fig 4.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 4.

Coronal T1-weighted MR image shows abnormal asymmetric thickening of the right superior oblique tendon (white arrow).

Fig 5.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 5.

Coronal T2-weighted fat-saturated MR image shows abnormal high signal intensity in the right superior oblique tendon.

Fig 6.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 6.

Coronal T1-weighted gadolinium-enhanced MR image shows mild abnormal enhancement of the right superior oblique tendon.

The diagnosis of inflammatory Brown syndrome was made, and she was treated with an initial 2-week course of 50-mg flurbiprofen 3 times a day and was given a frosted lens to aid her double vision. On 2-week review, her symptoms had improved, though she continued to have vertical double vision, particularly in her left gaze. She was prescribed a further 4-week course of flurbiprofen and is currently awaiting review in 6 weeks.

Discussion

Brown described the syndrome in 1950 and classified its etiology into true (congenital) and simulated (acquired) types.1 Congenital Brown syndrome is seen in those patients with a congenitally short or taut superior oblique tendon sheath complex. The acquired form replicates the clinical presentation of its congenital counterpart and differs only in its cause.2 Pathology commonly reveals swelling of the tendon associated with thickening of the sheath, and it has been postulated that the acquired form primarily involves the posterior fascia and tendon as a result of an inflammatory process.3 Various acquired causes have been reported, including rheumatoid arthritis,4 scleritis, systemic lupus erythematosus, trauma,5 and sinusitis6 and following peribulbar anesthetic injection.7

Previous reports have illustrated the use of CT as a valuable tool in assessing Brown syndrome.2 Imaging reveals thickening of the reflected portion of the superior oblique tendon, which may be accompanied by localized low attenuation representing edema. These features were not clearly present on the CT images of our patient.

To our knowledge, the features of the disease on MR imaging have yet to be described in the literature. This case clearly demonstrated abnormal thickening of the tendon on T1-weighted imaging, abnormal high signal intensity on T2-weighted fat suppression, and abnormal enhancement on T1-weighted gadolinium-enhanced imaging. These findings support an inflammatory and edematous pathologic process. SLE is a known cause of acquired Brown syndrome, and the patient's symptoms improved with nonsteroidal anti-inflammatory therapy. The literature supports conservative management of acquired Brown syndrome because the results of surgery to reduce the tethering caused by scarring in the region of the trochlea are generally disappointing.5

This case shows that MR imaging can play an important role in the identification of Brown syndrome and should be considered in cases where CT fails to confirm the abnormality.

References

  1. 1.↵
    1. Allen JH
    1. Brown HW
    . Congenital structural muscle anomalies. In Allen JH ed. Strabismus Ophthalmic Symposium. St Louis: Mosby; 1950:205–36
  2. 2.↵
    1. Mafee MF,
    2. Folk ER,
    3. Langer BG,
    4. et al
    . Computed tomography in the evaluation of brown syndrome of the superior oblique tendon sheath. Radiology 1985;154:691–95
    PubMed
  3. 3.↵
    1. Killian PJ,
    2. McClain B,
    3. Lawless OJ
    . Brown's syndrome: an unusual manifestation of rheumatoid arthritis. Arthritis Rheum 1977;20:1080–84
    PubMed
  4. 4.↵
    1. Sanford-Smith JH
    . Intermittent superior oblique tendon sheath syndrome: a case report. Br J Opthalmol 1969;53:412–17
    FREE Full Text
  5. 5.↵
    1. Mein J,
    2. Harcourt B
    . Diagnosis and Management of Ocular Motility Disorders. Oxford, UK: Blackwell Scientific Publications; 1986:301–04
  6. 6.↵
    1. Clarke E
    . A case of apparent intermittent overaction of the left superior oblique. Br J Ophthalmol 1966;23:116–17
  7. 7.↵
    1. Erie JC
    . Acquired Brown's syndrome after peribulbar anesthesia. Am J Opthalmol 1990;109:349–50
    PubMed
  • Received January 30, 2009.
  • Accepted after revision February 7, 2009.
  • Copyright © American Society of Neuroradiology
View Abstract
PreviousNext
Back to top

In this issue

American Journal of Neuroradiology: 30 (9)
American Journal of Neuroradiology
Vol. 30, Issue 9
1 Oct 2009
  • Table of Contents
  • Index by author
Advertisement
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on American Journal of Neuroradiology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
MR Imaging Features of Acquired Brown Syndrome
(Your Name) has sent you a message from American Journal of Neuroradiology
(Your Name) thought you would like to see the American Journal of Neuroradiology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
MR Imaging Features of Acquired Brown Syndrome
S. Currie, T. Goddard
American Journal of Neuroradiology Oct 2009, 30 (9) 1778-1779; DOI: 10.3174/ajnr.A1591

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
MR Imaging Features of Acquired Brown Syndrome
S. Currie, T. Goddard
American Journal of Neuroradiology Oct 2009, 30 (9) 1778-1779; DOI: 10.3174/ajnr.A1591
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
Purchase

Jump to section

  • Article
    • Abstract
    • Case Report
    • Discussion
    • References
  • Figures & Data
  • Info & Metrics
  • References
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Crossref
  • Google Scholar

This article has not yet been cited by articles in journals that are participating in Crossref Cited-by Linking.

More in this TOC Section

  • Correlation of Apparent Diffusion Coefficient at 3T with Prognostic Parameters of Retinoblastoma
  • Parathyroid Lesions: Characterization with Dual-Phase Arterial and Venous Enhanced CT of the Neck
  • Comparison of Contrast Effect on the Cochlear Perilymph after Intratympanic and Intravenous Gadolinium Injection
Show more Head and Neck

Similar Articles

Advertisement

News and Updates

  • Lucien Levy Best Research Article Award
  • Thanks to our 2020 Distinguished Reviewers
  • Press Releases

Resources

  • Evidence-Based Medicine Level Guide
  • How to Participate in a Tweet Chat
  • AJNR Podcast Archive
  • Ideas for Publicizing Your Research
  • Librarian Resources
  • Terms and Conditions

Opportunities

  • Share Your Art in Perspectives
  • Get Peer Review Credit from Publons
  • Moderate a Tweet Chat

American Society of Neuroradiology

  • Neurographics
  • ASNR Annual Meeting
  • Fellowship Portal
  • Position Statements

© 2021 by the American Society of Neuroradiology | Print ISSN: 0195-6108 Online ISSN: 1936-959X

Powered by HighWire