VISUAL VIGNETTE
Injury of the Oculomotor Nerve After Aneurysmal Subarachnoid Hemorrhage: Diffusion Tensor Tractography Study You Sung Seo, MS, Chul Hoon Chang, MD, Young Jin Jung, MD, and Sung Ho Jang, MD From the Departments of Physical Medicine and Rehabilitation (YSS, SHJ) and Neurosurgery (CHC, YJJ), College of Medicine, Yeungnam University, Daegu, Republic of Korea. Supported by the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology (2012R1A1A4A01001873). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. 0894-9115/15/9406-e51 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000270
A
75-yr-old female patient was diagnosed as having spontaneous subarachnoid hemorrhage due to a rupture of the left posterior communicating artery aneurysm and underwent coiling at the neurosurgery department of a university hospital (Fig. 1A). Brain magnetic resonance imaging taken at 6 wks after onset showed no definite lesion in the midbrain (Fig. 1B). Her left eyelid showed complete ptosis, and her left eye was deviated outward and downward in primary position. She could not move her left eye in the medial direction, and her left pupil was mildly dilated and nonreactive to light. She also complained of diplopia. Diffusion tensor imaging data were acquired at 6 wks after onset using a six-channel head coil on a 1.5-T Philips Gyroscan Intera. Imaging parameters were as follows: acquisition matrix, 96 96; reconstructed to matrix, 192 192 matrix; field of view, 240 240 mm2; repetition time, 10,398 msec; echo time, 72 msec; parallel imaging reduction factor, 2; echo planar imaging factor, 59; b value, 1000 sec/mm2; and a slice thickness of 2.5 mm. Oculomotor nerves were reconstructed using DTI-Studio software and fibers passing through two regions of interest with a fractional anisotropy of greater than 0.2 and a tract turning angle of less than 60 degrees. For reconstruction of the oculomotor nerve, we used two regions of interest with an option of cut operation on the axial images. The first region of interest was placed at the periaqueductal region according to known anatomy. The second region of interest was placed on the oculomotor nerve area.1
All correspondence and requests for reprints should be addressed to: Sung Ho Jang, MD, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu, 705-717, Republic of Korea.
FIGURE 1 A, Brain computed tomographic scan at onset shows subarachnoid hemorrhage. B, T2-weighted brain magnetic resonance images at 6 wks after onset show no specific lesion in the midbrain. C, Diffusion tensor tractography of the left oculomotor nerve showed a discontinuation (blue arrow) in the area where the left nerve exited the midbrain. On the axial color map of the midbrain, a defect was observed in the anteromedial portion of the left midbrain (yellow arrow).
Diffusion tensor tractography of the left oculomotor nerve showed a discontinuation distally after exiting the midbrain, compared with the right oculomotor nerve (Fig. 1C). On the axial color map of the midbrain, a defect was observed in the anteromedial portion of the left midbrain. In this patient, the visual dysfunctions of the left eye (ptosis, limitation of eye movement, diplopia, and mydriasis) seemed to be ascribed to injury of the left oculomotor nerve. The pathogenetic mechanisms of neurologic injury after spontaneous subarachnoid hemorrhage have not been clearly elucidated. Recent studies have reported that injury of the midbrain can be caused by hematoma into the perimesencephalic cisterns after spontaneous subarachnoid hemorrhage.2 In conclusion, we report on a patient with injury of the oculomotor nerve after aneurysmal spontaneous subarachnoid hemorrhage, which was demonstrated on diffusion tensor imaging. A few studies using diffusion tensor imaging have demonstrated injury of the oculomotor nerve in patients with brain injury.1,3,4 In 2006, Yamada et al.1 reported on a patient who showed injury of the oculomotor Visual Vignette
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nerve attributed to cerebral infarct in the midbrain. In 2013, Kwon et al.3 reported on a patient with injury of the oculomotor nerve after diffuse axonal injury. Recently, Kwon and Jang4 demonstrated the recovery of an injured oculomotor nerve in a patient with intracerebral hemorrhage. REFERENCES 1. Yamada K, Shiga K, Kizu O, et al: Oculomotor nerve palsy evaluated by diffusion-tensor tractography. Neuroradiology 2006;48:434Y7
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Visual Vignette
2. Schwartz TH, Solomon RA: Perimesencephalic nonaneurysmal subarachnoid hemorrhage: Review of the literature. Neurosurgery. 1996;39:433Y40 3. Kwon HG, Kim MS, Kim SH, et al: Injury of the oculomotor nerve in a patient with traumatic brain injury: Diffusion tensor tractography study. J Neurol Neurosurg Psychiatry 2013;84:1073Y4 4. Kwon HG, Jang SH: Recovery of injured oculomotor nerve in a patient with intracerebral hemorrhage. Am J Phys Med Rehabil 2014;93:1107Y8
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Injury of the Oculomotor Nerve After Aneurysmal Subarachnoid Hemorrhage: Diffusion Tensor Tractography Study You Sung Seo, MS, Chul Hoon Chang, MD, Young Jin Jung, MD, and Sung Ho Jang, MD From the Departments of Physical Medicine and Rehabilitation (YSS, SHJ) and Neurosurgery (CHC, YJJ), College of Medicine, Yeungnam University, Daegu, Republic of Korea. Supported by the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology (2012R1A1A4A01001873). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. 0894-9115/15/9406-e51 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000270
A
75-yr-old female patient was diagnosed as having spontaneous subarachnoid hemorrhage due to a rupture of the left posterior communicating artery aneurysm and underwent coiling at the neurosurgery department of a university hospital (Fig. 1A). Brain magnetic resonance imaging taken at 6 wks after onset showed no definite lesion in the midbrain (Fig. 1B). Her left eyelid showed complete ptosis, and her left eye was deviated outward and downward in primary position. She could not move her left eye in the medial direction, and her left pupil was mildly dilated and nonreactive to light. She also complained of diplopia. Diffusion tensor imaging data were acquired at 6 wks after onset using a six-channel head coil on a 1.5-T Philips Gyroscan Intera. Imaging parameters were as follows: acquisition matrix, 96 96; reconstructed to matrix, 192 192 matrix; field of view, 240 240 mm2; repetition time, 10,398 msec; echo time, 72 msec; parallel imaging reduction factor, 2; echo planar imaging factor, 59; b value, 1000 sec/mm2; and a slice thickness of 2.5 mm. Oculomotor nerves were reconstructed using DTI-Studio software and fibers passing through two regions of interest with a fractional anisotropy of greater than 0.2 and a tract turning angle of less than 60 degrees. For reconstruction of the oculomotor nerve, we used two regions of interest with an option of cut operation on the axial images. The first region of interest was placed at the periaqueductal region according to known anatomy. The second region of interest was placed on the oculomotor nerve area.1
All correspondence and requests for reprints should be addressed to: Sung Ho Jang, MD, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu, 705-717, Republic of Korea.
FIGURE 1 A, Brain computed tomographic scan at onset shows subarachnoid hemorrhage. B, T2-weighted brain magnetic resonance images at 6 wks after onset show no specific lesion in the midbrain. C, Diffusion tensor tractography of the left oculomotor nerve showed a discontinuation (blue arrow) in the area where the left nerve exited the midbrain. On the axial color map of the midbrain, a defect was observed in the anteromedial portion of the left midbrain (yellow arrow).
Diffusion tensor tractography of the left oculomotor nerve showed a discontinuation distally after exiting the midbrain, compared with the right oculomotor nerve (Fig. 1C). On the axial color map of the midbrain, a defect was observed in the anteromedial portion of the left midbrain. In this patient, the visual dysfunctions of the left eye (ptosis, limitation of eye movement, diplopia, and mydriasis) seemed to be ascribed to injury of the left oculomotor nerve. The pathogenetic mechanisms of neurologic injury after spontaneous subarachnoid hemorrhage have not been clearly elucidated. Recent studies have reported that injury of the midbrain can be caused by hematoma into the perimesencephalic cisterns after spontaneous subarachnoid hemorrhage.2 In conclusion, we report on a patient with injury of the oculomotor nerve after aneurysmal spontaneous subarachnoid hemorrhage, which was demonstrated on diffusion tensor imaging. A few studies using diffusion tensor imaging have demonstrated injury of the oculomotor nerve in patients with brain injury.1,3,4 In 2006, Yamada et al.1 reported on a patient who showed injury of the oculomotor Visual Vignette
www.ajpmr.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
e51
nerve attributed to cerebral infarct in the midbrain. In 2013, Kwon et al.3 reported on a patient with injury of the oculomotor nerve after diffuse axonal injury. Recently, Kwon and Jang4 demonstrated the recovery of an injured oculomotor nerve in a patient with intracerebral hemorrhage. REFERENCES 1. Yamada K, Shiga K, Kizu O, et al: Oculomotor nerve palsy evaluated by diffusion-tensor tractography. Neuroradiology 2006;48:434Y7
e52
Visual Vignette
2. Schwartz TH, Solomon RA: Perimesencephalic nonaneurysmal subarachnoid hemorrhage: Review of the literature. Neurosurgery. 1996;39:433Y40 3. Kwon HG, Kim MS, Kim SH, et al: Injury of the oculomotor nerve in a patient with traumatic brain injury: Diffusion tensor tractography study. J Neurol Neurosurg Psychiatry 2013;84:1073Y4 4. Kwon HG, Jang SH: Recovery of injured oculomotor nerve in a patient with intracerebral hemorrhage. Am J Phys Med Rehabil 2014;93:1107Y8
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
