MR imaging of the diplopia patient: optimum protocol, structured report, and differential diagnosis. Poster No.: C-2068 Congress: ECR 2012 Type: Educational Exhibit Authors: U. Kiendys, M. Lemmerling, C. Vande Walle, K. L. Verstraete ; 1 1 2 1 1 2 Gent/BE, Beervelde/BE Keywords: Neuroradiology brain, MR, Imaging sequences, Structured reporting, Pathology DOI: 10.1594/ecr2012/C-2068 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 47
Learning objectives To provide an optimum MRI protocol, a structured report, and a differential diagnostic overview of lesions detected in patients with diplopia. MRI is an excellent technique to investigate patients with diplopia, and helps to detect lesions in a variety of locations. In order not to overlook these lesions a correct (complete) examination has to be performed, followed by a structured way of reporting this exam. Background A) Diplopia: definition and etiologies diplous (double) + ops (eye) = double vision the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other Binocular diplopia = 'true diplopia', corrected by covering either eye. Related to orbital and neurologic disorders (in the orbit, superior orbital fissure, cavernous sinus, subarachnoid space anterior to the midbrain, brainstem and brain). (Tabel 1) Monocular diplopia persists despite covering the other eye. Related to disorders of the eye (scar of the cornea, iris lesions, cataract, lens luxations, seldom retinal lesions).this is not the focus of this poster. Binocular diplopia: etiologies 1. Orbital or ocular displacement (tumor) 2. Extraocular muscle diseases (restriction, weakness eg Graves' disease) 3. Neuromuscular junction dysfunction, eg myasthenia gravis 4. Cranial nerve dysfunction n.3, n.4, n.6 a. Superior orbital fissure Page 2 of 47
b. Cavernous sinus c. Cisternal segment - Interpeduncular cistern: n.3, n.4 - Prepontine cistern: n.6 5. Dysfunction of brainstem nuclei (stroke or tumor) 6. Brain: supranuclear dysfunctions (stroke or tumor) Tabel 1. Overview of different ethiologies of binocular diplopia. Solely number 1, 4, 5 and 6 are the subject of this poster. B) Cranial nerves responsible for ocular mobilty: In order not to overlook any lesions thorough knowledge of the course of the oculomotor, trochlear and abducens nerves is necessary. Oculomotor nerve (n.3) Page 3 of 47
Fig. 1: Oculomotor nerve References: U. Kiendys; Gent, BELGIUM 1. Nuclear portion (purple): in midbrain tegmentum 2. Intraparenchymal midbrain portion (green): - Runs through the red nucleus - Emerges medially at cerebral peduncle 3. Subarachnoid portion (yellow) (Fig. 2 on page 9): - Anterior to midbrain - Close to posterior communicating artery 4. Cavernous sinus portion: - Runs cranially (vulnerable to sellar involvement) 5. Orbital portion: - Superior orbital fissure where it divides into: Page 4 of 47
- superior division innervates levator palpebrae m.,superior rectus m. - inferior division innervates medial and inferior rectus mm., inferior oblique m., ciliary muscle and pupil sphincter Trochlear nerve (n. 4) Fig. 3: Trochlear nerve References: U. Kiendys; Gent, BELGIUM 1. Nuclear en intraparenchymal portion (green): - In midbrain tegmentum (colliculus inferior) below the nucleus of the n.3 - Decussates and exits dorsally just below the inferior colliculus 2. Subarachnoid portion (yellow): Page 5 of 47
- Circles anteriorly around the brainstam toward the eye - Passes between posterior cerebral artery and superior cerebellar artery 3. Cavernous sinus portion (blue): - Runs under n.3 in de lateral wall of the sinus cavernosus 4. Orbital portion (red): - Superior orbital fissure (innervates the superior oblique muscle) Abducens nerve (n.6) Fig. 4: Nuclear portion and intraparenchymal midbrain portion of trochlear nerve References: U. Kiendys; Gent, BELGIUM 1. Nuclear portion: - In the pons just ventral to the floor of the 4th ventricle (close to the facial nerve nucleus) 2. Intraparenchymal midbrain portion: - Runs through the pons anteriorly Page 6 of 47
3. Subarachnoid portion (Fig. 5 on page 14): - In the prepontine cistern towards Dorello's canal (where it pierces the dura) - Longest subarachnoid course of all cranial nerves (most vulnerable for increased intracranial pressure) 4. Cavernous sinus portion: - Runs lateral to the internal carotid artery 5. Orbital portion: - Superior orbital fissure (lateral rectus muscle) Superior orbital fissure is a cleft between greater and lesser sphenoid wing, passed by: oculomotor nerve (n.3) superior and inferior division trochlear nerve (n.4) ophtalmic nerve branches (n.5a): lacrimal n., nasociliary n., frontal n. abducens nerve (n.6) opthalmic vein sympathetic nerve fibres Superior orbital fissure is filled with fat en must be hyperintense on T1 weighted images. Page 7 of 47
Fig. 6: Superior orbital fissure References: M. Lemmerling; Beervelde, BELGIUM and http:// www.dontbeasalmon.net/archives/2010/03/anatomy-the-orb.html Cavernous sinus is a venous cavity bordered by the temporal and the sphenoid bone, lateral to the sella turcica, which contains: From superior to inferior (within the lateral wall of the sinus): oculomotor nerve (n.3) trochlear nerve (n.4) opthalmic nerve (n.5a) maxillar nerve (n.5b) From medial to lateral: internal carotid artery abducens nerve (n.6) (only nerve to run inside the cavernous sinus) Page 8 of 47
Fig. 7: Cavernous sinus References: M. Lemmerling; Beervelde, BELGIUM and Choong K et al (2010) Pituitary macroadenoma with invasion into cavernous sinus, cranial nerve palsies. Endocrine Today Images for this section: Page 9 of 47
Fig. 2: Subarachnoid portion of oculomotor nerve on thin sliced heavily T2-weighted images Page 10 of 47
Fig. 7: Cavernous sinus Page 11 of 47
Fig. 1: Oculomotor nerve Page 12 of 47
Fig. 3: Trochlear nerve Page 13 of 47
Fig. 4: Nuclear portion and intraparenchymal midbrain portion of trochlear nerve Page 14 of 47
Fig. 5: Subarachnoid portion of abducens nerve on thin sliced heavily T2-weighted images Page 15 of 47
Fig. 6: Superior orbital fissure Page 16 of 47
Imaging findings OR Procedure details A) Suggested imaging technique MRI: 1. Standard sequences: - axial T2WI of the brain and brain stem (5 mm) - axial T1WI of the orbit (1-3 mm) - heavily weighted axial T2WI of the cisternal segment (0.5-1 mm) - axial and coronal T1WI after IV Gd 2. Optional sequences: - DWI in the elderly: suspicion of ischemia (case 1) - FLAIR WI in young patients: suspicion of MS (case 2) - MRA of Willis' circle in oculomotor nerve disease: suspicion of aneurysm (case 3) Page 17 of 47
Fig. 8: MRI technique References: M. Lemmerling; Beervelde, BELGIUM B) Structured report: Stucture to be inspected Most frequent anomaly in this location 1. brain and brainstem nuclei stroke, or tumor 2. cisternal segment infectious, or malignant meningeal disease 3. cavernous sinus infectious disaese, sellar mass 4. superior orbital fissure tumor 5. orbit Structured report tumor, or cellulitis Page 18 of 47
C) Cranial nerve pathology causing diplopia: 1. Nuclear portion and intraparenchymal midbrain portion: Small infarcts in nuclear portion and larger in midbrain portion; trochlear nerve palsy is least frequent (when occurs is contralateral (case 1)); ipsilateral n.3 palsy; n.6 palsy, eventually with ipsilateral n.7 palsy (facial numbness or weakness, vertigo, hearing loss). 2. Subarachnoid portion: - Aneurysm posterior communicating artery: isolated n. 3 palsy or with sudden headache, stiff neck, loss of consciousness (case 3). - Meningeal disease: infectious/malignant/miscellanous: headache, stiff neck, fever, involvement other cranial nerves eg with hearing loss (case 5). - Most frequent pathology of n.4 is due to trauma due its very long subarachnoid course, but n.6 is most vulnerable to generalized increase in intracranial pressure due its very steep course anterior from de pons. 3. Cavernous sinus portion: - Invasive (sellar) mass: mostly isolated n. 3 palsy (case 6-9). - Infectious disease: palsy of different cranial nerves, also with trigeminal pain. - Tortuosity ICA or aneurysm: mostly isolated n.6 palsy. 4. Orbital portion: Cellulitis, tumor or mass: combination of n.3, n.4, n.6 palsy, pain in the eye, proptosis (case 10-12). D) Cases: Page 19 of 47
Fig. 9: Case 1. Ischemia. References: M. Lemmerling; Beervelde, BELGIUM Page 20 of 47
Fig. 10: Case 2. Multiple sclerosis. References: M. Lemmerling; Beervelde, BELGIUM Page 21 of 47
Fig. 11: Case 3. Right PCA aneurysm. References: M. Lemmerling; Beervelde, BELGIUM Page 22 of 47
Fig. 12: Case 4. Lipoma. References: M. Lemmerling; Beervelde, BELGIUM Page 23 of 47
Fig. 13: Case 5. Lymphomatous meningitis. References: M. Lemmerling; Beervelde, BELGIUM Page 24 of 47
Fig. 14: Case 6. Pituitary adenoma. References: M. Lemmerling; Beervelde, BELGIUM Page 25 of 47
Fig. 15: Case 7. Cavernosus sinus meningioma. References: M. Lemmerling; Beervelde, BELGIUM Page 26 of 47
Fig. 16: Case 8. Pituitary apoplexy. References: M. Lemmerling; Beervelde, BELGIUM Page 27 of 47
Fig. 17: Case 9. Clival metastasis. References: M. Lemmerling; Beervelde, BELGIUM Page 28 of 47
Fig. 18: Case 10. Spinocellular epithelioma with expantion in superior orbital fissure. References: M. Lemmerling; Beervelde, BELGIUM Page 29 of 47
Fig. 19: Case 11. Retroocular metastases. References: M. Lemmerling; Beervelde, BELGIUM Page 30 of 47
Fig. 20: Case 12. Inflammatory mass in the left orbit. References: M. Lemmerling; Beervelde, BELGIUM Images for this section: Page 31 of 47
Fig. 9: Case 1. Ischemia. Page 32 of 47
Fig. 10: Case 2. Multiple sclerosis. Page 33 of 47
Fig. 11: Case 3. Right PCA aneurysm. Page 34 of 47
Fig. 12: Case 4. Lipoma. Page 35 of 47
Fig. 13: Case 5. Lymphomatous meningitis. Page 36 of 47
Fig. 14: Case 6. Pituitary adenoma. Page 37 of 47
Fig. 15: Case 7. Cavernosus sinus meningioma. Page 38 of 47
Fig. 16: Case 8. Pituitary apoplexy. Page 39 of 47
Fig. 17: Case 9. Clival metastasis. Page 40 of 47
Fig. 18: Case 10. Spinocellular epithelioma with expantion in superior orbital fissure. Page 41 of 47
Fig. 19: Case 11. Retroocular metastases. Page 42 of 47
Fig. 20: Case 12. Inflammatory mass in the left orbit. Page 43 of 47
Conclusion A wide variety of lesions can cause diplopia. It is very important that MRI examination is complete (skull base, brain stem, complete brain) and tailored (~ age, clinical signs) (Fig. 21 on page 44). It will be helpful to follow this checklist during report: superior orbital fissure, cavernous sinus, interpeduncular and prepontine cistern, midbrain (tegmentum), superior and inferior colliculus (tectum). Fig. 22: Structured report and most frequent pathology. References: M. Lemmerling; Beervelde, BELGIUM Images for this section: Page 44 of 47
Fig. 21: Imaging technique. Page 45 of 47
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