Isolated internuclear ophthalmoplegia after massive supratentorial epidural hematoma: a case report and review of literature

• Published in: World neurosurgery Vol. 100; pp. 712.e5 - 712.e13
• Main Authors: Chen, Ko-Ting, MD, Lin, Tzu-Kang, MD, Hsieh, Tsung-Che, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2017
• Subjects: Brainstem infarction; Female; Hematoma, Epidural, Cranial - surgery; Humans; Internuclear ophthalmoplegia; Medial longitudinal fasciculus; Middle Aged; Neurosurgery; Ocular Motility Disorders - diagnosis; Ocular Motility Disorders - etiology; Postoperative Complications - diagnosis; Traumatic brain injury; computed tomography; HISS; magnetic resonance imaging; MRI; MLF; traumatic brain injury; EDH; head injury severity scale; Glasgow coma scale; INO; CT; epidural hematoma; internuclear ophthalmoplegia; brain stem infarction; GCS; medial longitudinal fasciculus; TBI; Internuclear ophthalmoplegia; Traumatic brain injury; Brainstem infarction; Medial longitudinal fasciculus
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2017.01.071

Abstract Background Isolated Internuclear ophthalmoplegia (INO) following traumatic brain injury (TBI) is rare, with the majority of reported patients suffering from minor head injuries. We report a patient with INO after a massive supratentorial epidural hematoma. We review the literature published since 1966, to summarize the mechanisms of injury and clinical outcomes of INO after TBI. Case Description and Literature Review A 54-year-old woman suffered from isolated INO 10 hours after emergent evacuation of a massive supratentorial epidural hematoma. The brainstem displacement caused by downward herniation led to a deficient blood supply. Magnetic resonance imaging showed an infarct at the right dorsal-medial pons. Her symptoms partially improved by 1.5 months postoperatively. A total of 27 patients, including ours, with INO after TBI have been reported over the past 50 years. Young male patients (mean age, 30.8 years; male, 67%) are more common, and INO tends to be bilateral (67%). Infarction, hemorrhage, and fiber injury are nearly equally responsible for causing INO (35%, 35%, 30%, respectively). Most patients recover spontaneously; 65% gain full recovery at a median time of 3 months, and 91% have at least partial recovery at 4.5 months. The median time for full recovery after infarct, hemorrhage, and fiber injury is 12, 90, and 150 days, respectively. Conclusions INO should be in the differential diagnosis of TBI patients with an adduction deficit, despite the condition’s rarity. Isolated INO is a relatively benign sequela of TBI, with all but 1 reported patient achieving at least partial recovery over 12 months.