Oculomotor paralysis: 3D-CISS MR imaging with MPR in the evaluation of neuralgic manifestation and the adjacent structures

doi:10.1016/j.ejrad.2008.11.004

European Journal of Radiology

Volume 73, Issue 2, February 2010, Pages 221-223

https://doi.org/10.1016/j.ejrad.2008.11.004 Get rights and content

Abstract

Purpose

To evaluate the value of three-dimensional (3D) constructive interference in steady-state (CISS) magnetic resonance (MR) imaging with multi-planar reconstruction (MPR) in displaying the relationship between the oculomotor nerve and its adjacent structures for patients with oculomotor paralysis.

Materials and methods

17 consecutive patients with oculomotor paralysis were examined with 3D-CISS and conventional spin-echo (SE) sequences on a 1.5-Tesla MR system. Original transverse and MPR images were used for image interpretation. The features of the oculomotor nerve and its adjacent structures were identified. The diagnosis was surgically confirmed in all patients.

Results

Through 3D-CISS with MPR images, obvious relationship of the oculomotor nerve and its adjacent structures was demonstrated on 17 patients. Of those oculomotor nerves, 15 were compressed by the arteries (n = 15), one by the craniopharyngioma (n = 1), and another one by the neurofibroma (n = 1).

Conclusion

3D-CISS MR imaging with MPR provides an excellent way to characterize the relationship between the nerve and its adjacent structures in the cisternal segment of the oculomotor nerve in the patients with oculomotor paralysis. Moreover, this method shows anatomical details for imaging diagnosis and surgical procedure.

Introduction

The oculomotor nerve, namely, cranial nerve III, is difficult to be visualized on conventional magnetic resonance (MR) images because of its small diameter and complex anatomic course [1], [2], [3], [4], [5]. In recent years, with the development of MR hydrography techniques, it has been possible to image the normal cisternal segment of the cranial nerve using three-dimensional (3D) constructive interference in steady-state (CISS) MR sequence [6], [7], [8], [9], [10]. For a more accurate surgical procedure in patients with oculomotor paralysis, it is extremely important to have a clear understanding of the exact anatomic relationship between the oculomotor nerve and its adjacent structures before the surgery. Although the normal anatomic appearances of the oculomotor nerve using 3D-CISS sequence have been illustrated in the literature, to the best of our knowledge, a detailed MR imaging description of the oculomotor nerve and its adjacent structures in patients with oculomotor paralysis has not been described so far.

Therefore, the purpose of this study was to establish and clarify the MR imaging anatomic relationship between the oculomotor nerve and its adjacent structures in patients with oculomotor paralysis using 3D-CISS MR imaging and MPR technique.

Section snippets

Patients

17 consecutive patients with oculomotor paralysis (11 men and 6 women) were included in this study. Their ages ranged from 45 to 73 years (mean age of 63 years). Conventional MR imaging was used to confirm that patients had no multiple sclerosis.

The study protocol was approved by the institutional review board and informed consent was obtained from all patients.

MR imaging

All MR imaging examinations were performed on a 1.5-Tesla unit (Magneto Sonata; Siemens, Erlangen; Germany) with a regular head coil.

Results

In all patients, it has been demonstrated that there is an obvious relationship between the oculomotor nerve and its adjacent structures on 3D-CISS with MPR images. Of the 17 patients with 34 oculomotor nerves, 20 nerves were compressed on the left, and the other 14 on the right. On 3D-CISS images, it was identified that 18 out of 34 oculomotor nerves were compressed by posterior cerebral artery (PCA) on different direction (Fig. 1, Fig. 2, Fig. 3, Fig. 4). Specifically, it was discovered that

Discussion

3D-CISS MR sequence is a high-spatial-resolution, refocused gradient-echo MR imaging sequence that is flow compensated. It generates a steady state contribution of the transverse magnetization for tissues with long T2 and is therefore called T2 weighted [6], [10]. Moreover, 3D-CISS sequence can provide high-resolution images with excellent contrast between cerebrospinal fluid (CSF) and solid structures, and therefore, 3D-CISS images play an important role to MR cisternography [6], [7], [8], [9]

Conflict of interest

The authors did not receive any outside funding or grants in support of this research for or preparation of the work. So we certify that there is no actual or potential conflict of interest in relation to this article.

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La paralysie brutale unilatérale du nerf oculomoteur commun est due fréquemment à une compression par un anévrysme. Mais il a été rapporté, dans de rares cas, la compression de ce nerf par l’artère cérébrale postérieure.
On rapporte le cas d’une femme âgée de 45 ans qui s’est présenté à l’hôpital pour une paralysie brutale du nerf oculomoteur commun droit sans notion de céphalée. On a réalisé pour cette patiente une IRM sur une machine 3 Tesla, les séquences conventionnelles n’ont pas montré d’anomalie, mais la séquence CISS-3D a pu monter une compression du nerf oculomoteur commun droit par l’artère cérébrale postérieure homolatérale.
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Sudden onset, unilateral third nerve palsy is frequently caused by oculomotor nerve compression from an aneurysm. It has also been reported, in rare cases, to be caused by vascular compression by the posterior cerebral artery.
We report the case of a 45-year-old woman who presented at hospital with sudden onset right third nerve palsy without a history of headaches. She was examined on a 3 Tesla MR System with conventional sequences that were found normal, and so completed with a three-dimensional (3D) constructive interference steady-state (CISS) magnetic resonance (MR) imaging with multi-planar reconstruction (MPR). This sequence revealed compression of the right oculomotor nerve by the right posterior cerebral artery.
3D-CISS MR imaging with multi-planar reconstruction is the optimal imaging method for displaying the relationship between the cisternal segment of the oculomotor nerve and its adjacent structures in patients with oculomotor paralysis. Moreover, it shows anatomical details for imaging diagnosis and surgical procedures.
Three dimensional MRI study: Safety of short versus long needle peribulbar anesthesia
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The single-injection technique for percutaneous peribulbar anesthesia with a short needle is a suitable alternative to the double-injection technique for cataract surgery.5,6 The needle is inserted transcutaneously through the lower eyelid directed into the inferotemporal quadrant with digital pressure applied by the thumb and index fingers around the needle hub during injection.4,7,8 However the insertion of longer needles increases the potential of injury to important structures.
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Fifty patients free of orbital pathology with normal axial length were selected for MRI with the 3D CISS sequence. Original axial and multiplanar image reconstruction (MPR) images were selected for image interpretation. Orbital structures were identified at 12.5 and 25 mm depths from the orbital rim to compare significant differences in anatomy between the two imaging planes at the expected needle depth and to assess the size of the globe and the orbit.
The cross sectional area of the extraocular muscles were statistically significantly smaller at the 12.5 mm plane (P = 0.001). The area of inferotemporal fat was statistically significantly larger at the 12.5 mm plane (P = 0.033). There was no statistical difference in the inferonasal and superonasal fat areas at different depths (P = 0.34, P = 0.35 respectively). The size of the orbit and globe was significantly larger at 12.5 mm (P = 0.001). There was no difference between depths in the presence or absence of neurovascular bundles and supporting structures including the intramuscular septae.
There is a larger structure-free space at a depth of 12.5 mm than at 25 mm. Therefore, the inference is that a needle inserted in the infero-temporal zone to a depth of 12.5 mm is less likely to injure the eyeball or extra-ocular muscles than one advanced to 25 mm.
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Additionally, herniation of the uncus medially across the free edge of the tentorium may impinge on the nerve. Oculomotor palsy may result from compression of CN III.c by tumors or neurovascular compression, with findings on CISS correlating well with those at surgery.24 Isolated reversible enhancement and thickening of CN III.c has been reported in ophthalmoplegic migraine by standard imaging25; one recent review of ophthalmoplegic migraine found that nerve thickening and enhancement is seen in 75% of cases diagnosed clinically.26
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The MRI findings of 80 patients with POND were reviewed and compared with digital subtraction angiography (DSA), operative or pathological results, and final clinical diagnosis.
Twenty-three aneurysms (23/26) confirmed by DSA were detected with Magnetic Resonance Angiography (MRA). Twenty-five inflammatory lesions, 14 malignant lesions, and 5 benign lesions involving PON were shown with 3D-CEMRI corresponding with clinical diagnosis and pathology. Another 13 (13/80, 16.03%) cases were negative on MRI.
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Oculomotor paralysis: 3D-CISS MR imaging with MPR in the evaluation of neuralgic manifestation and the adjacent structures

Abstract

Purpose

Materials and methods

Results

Conclusion

Introduction

Section snippets

Patients

MR imaging

Results

Discussion

Conflict of interest

Am J Ophthalmol

Surg Neurol

Anatomic relationship of the oculomotor nuclear complex and medial longitudinal fasciculus in the midbrain

Am J Neuroradiol

Cranial nerves III, IV, and VI

Top Magn Reson Imaging

Imaging the cranial nerves. Part I. Methodology, infectious and inflammatory, traumatic and congenital lesions

Eur Radiol

Three-dimensional-fast imaging employing steady-state acquisition and T2-weighted fast spin-echo magnetic resonance sequences on visualization of cranial nerves III–XII

Chin Med J (Engl)

Normal cranial nerves in the cavernous sinuses: contrast-enhanced three-dimensional constructive interference in the steady state MR imaging

Am J Neuroradiol