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Diffusion Tensor Imaging Tractography Detecting Isolated Oculomotor Nerve Damage After Traumatic Brain Injury
Clinical Images
Diffusion Tensor Imaging Tractography Detecting Isolated Oculomotor Nerve Damage After Traumatic Brain Injury Timothe´e Jacquesson1-3, Carole Frindel3, Francois Cotton3,4
Key words Diffusion tensor imaging - Oculomotor nerve - Tractography - Traumatic brain injury -
From the Departments of 1Neurosurgery B, Skull Base Multidisciplinary Unit, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, 2Anatomy, University of Lyon 1, and 4 Radiology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon; and 3CREATIS Laboratory, CNRS UMR 5220 e INSERM U1044, Villeurbanne, France
A 24-year-old woman was hit by a bus and suffered an isolated complete oculomotor nerve palsy. Computed tomography scan did not show a skull base fracture. T2*-weighted magnetic resonance imaging revealed petechial cerebral hemorrhages sparing the brainstem. T2 constructive interference in steady state suggested a partial sectioning of the left oculomotor nerve just before entering the superior orbital fissure. Diffusion tensor imaging fiber tractography confirmed a sharp arrest of the left oculomotor nerve. This recent imaging technique could be of interest to assess white fiber damage and help make a diagnosis or prognosis.
To whom correspondence should be addressed: Timothée Jacquesson, M.D., M.Sc. [E-mail: [email protected]] Supplementary digital content available online.
hours of surveillance in the intensive care unit, the patient quickly awoke without any remaining motor deficit. Surprisingly, she kept a total intrinsic Available online: www.sciencedirect.com and extrinsic oculomotor nerve palsy 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All that was confirmed by a rights reserved. thorough ophthalmologic examination (Video 1). She had no other neurologic symptom. A dedicated cerebral magnetic resonance Video available at WORLDNEUROSURGERY.org imaging (Achieva 3T, Philips INTRODUCTION Medical System, Best, Netherland) showed petechial A 24-year-old woman was a cerebral hemorrhages that spared the victim of a severe car crash. She initially brainstem (Figure 2). T2 constructive presented a Glasgow Coma Score of 8 interference in steady state suggested a (E2V2M4), a left hemiparesis (3/5), and a partial sectioning of the left oculomotor left pupil that was unreactive and dilated nerve just before entering the superior (11 mm). She also had a superficial orbital fissure, but the left posterior wound of the left fourth finger and mulcommunicating artery hampered the tiple subcutaneous hemorrhages. After radiologic analysis (Figure 3). Diffusion orotracheal intubation, she was transtensor imaging fiber tracking (Mrtrix3 ferred to our trauma center. Blood tests package software, J-D Tournier, Brain did not reveal any metabolic disorders or Research Institute, Melbourne, Australia; intoxication. The body scan found only fractional anisotropy threshold 0.3, disseminated petechial cerebral hemorcurvature angle 0.45 , minimum length: rhages without any fractures or other abnormalities. In particular, no skull base 10 mm, region of interest seeding: fractures were detected (Figure 1). The oculomotor nerve cisternal segment on transcranial Doppler did not show signs coronal cross section) confirmed a sharp of intracranial hypertension. After a few arrest of oculomotor fibers at this precise Citation: World Neurosurg. (2017). http://dx.doi.org/10.1016/j.wneu.2017.01.082 Journal homepage: www.WORLDNEUROSURGERY.org
WORLD NEUROSURGERY -: ---, MONTH 2017
point (Figure 4 and Video 2). Since the clinical trend was favorable, the woman was discharged home. However, there was no change in the left third cranial nerve palsy 6 months later. This case indicates that isolated cranial nerve palsy can occur in severe traumatic brain injury and could benefit from specific highresolution imaging to refine potential damages and future outcome. ACKNOWLEDGMENTS We are grateful to the Radiology Department of the Neurological Hospital Pierre Wertheimer of Lyon - France, that provided tailored MRI and CT-scan acquisitions. We warmly thank the Radiology staff and particularly Dr R. Ameli who allowed us to work on high quality pictures. Conflict of interest statement: We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. Received 7 December 2016; accepted 19 January 2017 Citation: World Neurosurg. (2017). http://dx.doi.org/10.1016/j.wneu.2017.01.082 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
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CLINICAL IMAGES TIMOTHÉE JACQUESSON ET AL.
DTI TRACTOGRAPHY DETECTING ISOLATED OCULOMOTOR NERVE DAMAGE POST TBI
Figure 1. Cerebral computed tomography scan in axial (A) and coronal (B) views. No visible skull base fracture, particularly in the para sellar area (red arrow) and the superior orbital fissure (yellow arrow).
Figure 2. Cerebral magnetic resonance imaging in axial view and T2* sequence. Petechial cerebral hemorrhages (A, yellow arrows) that spare cranial nerves and the brainstem (B).
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www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.01.082
CLINICAL IMAGES TIMOTHÉE JACQUESSON ET AL.
DTI TRACTOGRAPHY DETECTING ISOLATED OCULOMOTOR NERVE DAMAGE POST TBI
Figure 3. Cerebral magnetic resonance imaging in axial view and T2 constructive interference steady state sequence. Partial sectioning of the left oculomotor nerve in its cisternal segment just before entering the superior orbital fissure (yellow *). The posterior communicating artery courses posteriorly from the carotid artery termination, pinching the oculomotor with the superior cerebellar artery and hiding its trajectory (red arrow).
Figure 4. Diffusion tensor imaging tractography of the 2 oculomotor nerves superimposed on axial T2 constructive interference steady state sequence. Sharp arrest of left oculomotor nerve.
WORLD NEUROSURGERY -: ---, MONTH 2017
www.WORLDNEUROSURGERY.org
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Diffusion Tensor Imaging Tractography Detecting Isolated Oculomotor Nerve Damage After Traumatic Brain Injury Timothe´e Jacquesson1-3, Carole Frindel3, Francois Cotton3,4
Key words Diffusion tensor imaging - Oculomotor nerve - Tractography - Traumatic brain injury -
From the Departments of 1Neurosurgery B, Skull Base Multidisciplinary Unit, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, 2Anatomy, University of Lyon 1, and 4 Radiology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon; and 3CREATIS Laboratory, CNRS UMR 5220 e INSERM U1044, Villeurbanne, France
A 24-year-old woman was hit by a bus and suffered an isolated complete oculomotor nerve palsy. Computed tomography scan did not show a skull base fracture. T2*-weighted magnetic resonance imaging revealed petechial cerebral hemorrhages sparing the brainstem. T2 constructive interference in steady state suggested a partial sectioning of the left oculomotor nerve just before entering the superior orbital fissure. Diffusion tensor imaging fiber tractography confirmed a sharp arrest of the left oculomotor nerve. This recent imaging technique could be of interest to assess white fiber damage and help make a diagnosis or prognosis.
To whom correspondence should be addressed: Timothée Jacquesson, M.D., M.Sc. [E-mail: [email protected]] Supplementary digital content available online.
hours of surveillance in the intensive care unit, the patient quickly awoke without any remaining motor deficit. Surprisingly, she kept a total intrinsic Available online: www.sciencedirect.com and extrinsic oculomotor nerve palsy 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All that was confirmed by a rights reserved. thorough ophthalmologic examination (Video 1). She had no other neurologic symptom. A dedicated cerebral magnetic resonance Video available at WORLDNEUROSURGERY.org imaging (Achieva 3T, Philips INTRODUCTION Medical System, Best, Netherland) showed petechial A 24-year-old woman was a cerebral hemorrhages that spared the victim of a severe car crash. She initially brainstem (Figure 2). T2 constructive presented a Glasgow Coma Score of 8 interference in steady state suggested a (E2V2M4), a left hemiparesis (3/5), and a partial sectioning of the left oculomotor left pupil that was unreactive and dilated nerve just before entering the superior (11 mm). She also had a superficial orbital fissure, but the left posterior wound of the left fourth finger and mulcommunicating artery hampered the tiple subcutaneous hemorrhages. After radiologic analysis (Figure 3). Diffusion orotracheal intubation, she was transtensor imaging fiber tracking (Mrtrix3 ferred to our trauma center. Blood tests package software, J-D Tournier, Brain did not reveal any metabolic disorders or Research Institute, Melbourne, Australia; intoxication. The body scan found only fractional anisotropy threshold 0.3, disseminated petechial cerebral hemorcurvature angle 0.45 , minimum length: rhages without any fractures or other abnormalities. In particular, no skull base 10 mm, region of interest seeding: fractures were detected (Figure 1). The oculomotor nerve cisternal segment on transcranial Doppler did not show signs coronal cross section) confirmed a sharp of intracranial hypertension. After a few arrest of oculomotor fibers at this precise Citation: World Neurosurg. (2017). http://dx.doi.org/10.1016/j.wneu.2017.01.082 Journal homepage: www.WORLDNEUROSURGERY.org
WORLD NEUROSURGERY -: ---, MONTH 2017
point (Figure 4 and Video 2). Since the clinical trend was favorable, the woman was discharged home. However, there was no change in the left third cranial nerve palsy 6 months later. This case indicates that isolated cranial nerve palsy can occur in severe traumatic brain injury and could benefit from specific highresolution imaging to refine potential damages and future outcome. ACKNOWLEDGMENTS We are grateful to the Radiology Department of the Neurological Hospital Pierre Wertheimer of Lyon - France, that provided tailored MRI and CT-scan acquisitions. We warmly thank the Radiology staff and particularly Dr R. Ameli who allowed us to work on high quality pictures. Conflict of interest statement: We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. Received 7 December 2016; accepted 19 January 2017 Citation: World Neurosurg. (2017). http://dx.doi.org/10.1016/j.wneu.2017.01.082 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
1.E1
CLINICAL IMAGES TIMOTHÉE JACQUESSON ET AL.
DTI TRACTOGRAPHY DETECTING ISOLATED OCULOMOTOR NERVE DAMAGE POST TBI
Figure 1. Cerebral computed tomography scan in axial (A) and coronal (B) views. No visible skull base fracture, particularly in the para sellar area (red arrow) and the superior orbital fissure (yellow arrow).
Figure 2. Cerebral magnetic resonance imaging in axial view and T2* sequence. Petechial cerebral hemorrhages (A, yellow arrows) that spare cranial nerves and the brainstem (B).
1.E2
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.01.082
CLINICAL IMAGES TIMOTHÉE JACQUESSON ET AL.
DTI TRACTOGRAPHY DETECTING ISOLATED OCULOMOTOR NERVE DAMAGE POST TBI
Figure 3. Cerebral magnetic resonance imaging in axial view and T2 constructive interference steady state sequence. Partial sectioning of the left oculomotor nerve in its cisternal segment just before entering the superior orbital fissure (yellow *). The posterior communicating artery courses posteriorly from the carotid artery termination, pinching the oculomotor with the superior cerebellar artery and hiding its trajectory (red arrow).
Figure 4. Diffusion tensor imaging tractography of the 2 oculomotor nerves superimposed on axial T2 constructive interference steady state sequence. Sharp arrest of left oculomotor nerve.
WORLD NEUROSURGERY -: ---, MONTH 2017
www.WORLDNEUROSURGERY.org
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