Venous Angioma Associated With Atypical Ophthalmoplegic Migraine

Recurrent Painful Ophthalmoplegic Neuropathy: A case report with atypical features and a review of the literature

INTRODUCTION

Recurrent Painful Ophthalmoplegic Neuropathy, previously known as Ophthalmoplegic Migraine, is a poorly characterized disorder mainly because there are few cases described. We report a new case of Recurrent Painful Ophthalmoplegic Neuropathy and a review of the literature to contribute to increasing the knowledge of the clinical features of this disorder.

CASE REPORT AND REVIEW OF LITERATURE

A 45-year-old woman presented with adult-onset recurrent attacks of abducens and oculomotor palsy associated with diplopia followed by headache. Most notably, pain always presented many days after oculomotor impairment, a feature never described in the literature. A diagnosis of possible Recurrent Painful Ophthalmoplegic Neuropathy was made after excluding other possible mimicking disorders. Symptoms usually resolved gradually with corticosteroid therapy, albeit without a clear-cut benefit.Clinical data collected from 1989 to 2022 showed that adult onset in Recurrent Painful Ophthalmoplegic Neuropathy is not uncommon. While III cranial nerve palsy is typical, VI and IV nerve palsy have also been described.

PATHOPHYSIOLOGY AND DIAGNOSIS

Several hypotheses have been proposed, including nerve compression, ischemia or inflammation/demyelination, but none has been completely accepted.Diagnosis remains of exclusion; magnetic resonance imaging and blood exams are key in differential diagnosis.

CONCLUSIONS

Our case gives us the possibility to expand the clinical features of Recurrent Painful Ophthalmoplegic Neuropathy, also contributing to updating the pathophysiological hypotheses.

Oculomotor nerve tumors masquerading as recurrent painful ophthalmoplegic neuropathy: Report of two cases and review of the literature

Background

In recurrent painful ophthalmoplegic neuropathy (RPON) that was previously termed as ophthalmoplegic migraine, enhancement of the ocular motor cranial nerves could be seen in the cisternal segment during the acute phase. However, various tumors involving the oculomotor nerve may mimic RPON.

Methods

We report two patients with MRI findings of oculomotor nerve schwannoma who initially presented with RPON, and found through the literature review five more patients with oculomotor nerve tumors that masqueraded as RPON.

Results

All patients showed an involvement of the oculomotor nerve. The radiological or pathological diagnosis included schwannoma in five, venous angioma in one, and neuromuscular harmatoma in another one. MRIs with gadolinium documented an enhancing nodule involving the cisternal portion of the oculomotor nerve in six of them, which was also observed on follow-up MRIs without an interval change.

Conclusions

It should be recognized that an incomplete recovery may occur during future attacks in patients with otherwise uncomplicated RPON. Follow-up MRIs are required to detect tumors involving the ocular motor cranial nerves, especially in patients with suspected RPON when the recovery is incomplete.

Ophthalmoplegic "migraine" or recurrent ophthalmoplegic cranial neuropathy: new cases and a systematic review

Ophthalmoplegic migraine is a poorly understood neurologic syndrome characterized by recurrent bouts of head pain and ophthalmoplegia. By reviewing cases presenting to our centers in whom the phenotype has been carefully dissected, and systematically reviewing all published cases of ophthalmoplegic migraine in the magnetic resonance imaging (MRI) era, this review sets out to clearly define the syndrome and discuss possible etiologies. We found that in up to one-third of patients, the headache was not migrainous or associated with migrainous symptoms. In three-quarters of the cases involving the third nerve, there was focal nerve thickening and contrast enhancement on MRI. Observational data suggest systemic corticosteroids may be beneficial acutely. The etiology remains unclear, but may involve recurrent bouts of demyelination of the oculomotor nerve. "Ophthalmoplegic migraine" is a misnomer in that it is probably not a variant of migraine but rather a recurrent cranial neuralgia. A more appropriate name might be "ophthalmoplegic cranial neuropathy."

Infranuclear ocular motor disorders

This chapter covers the very large number of possible disorders that can affect the three ocular motor nerves, the neuromuscular junction, or the extraocular muscles. Conditions affecting the nerves are discussed under two major headings: those in which the site of damage can be anatomically localized (e.g., fascicular lesions and lesions occurring in the subarachnoid space, the cavernous sinus, the superior orbital fissure, or the orbit) and those in which the site of the lesion is either nonspecific or variable (e.g., vascular lesions, tumors, "ophthalmoplegic migraine," and congenital disorders). Specific comments on the diagnosis and management of disorders of each of the three nerves follow. Ocular motor synkineses (including Duane's retraction syndrome and aberrant regeneration) and disorders resulting in paroxysms of excess activity (e.g., neuromyotonia) are then covered, followed by myasthenia gravis and other disorders that affect the neuromuscular junction. A final section discusses disorders of the extraocular muscles themselves, including thyroid disease, orbital myositis, mitochondrial disease, and the muscular dystrophies.

Cerebral developmental venous anomalies

INTRODUCTION

Cerebral developmental venous anomalies (DVAs) are the most frequently encountered cerebral vascular malformation. As such, they are often observed incidentally during routine CT and MRI studies. Yet, what DVAs represent from a clinical perspective is frequently not common knowledge and DVAs, therefore, still generate uncertainty and concern amongst physicians. This article reviews our current understanding of developmental venous anomalies.

RESULTS

In the majority of cases, DVAs follow a benign clinical course. On rare occasions, DVAs become symptomatic generally due to an underlying associated vascular malformation such as cavernous malformations or thrombosis of the collecting vein. Rare forms of DVAs include arterialized DVAs and DVAs involved in the drainage of sinus pericranii, which warrant additional investigation by digital subtraction angiography. Cerebral abnormalities such as atrophy, white matter lesions and calcifications within the drainage territory of asymptomatic DVAs, are often identified on CT or MR imaging studies and likely represent secondary changes due to venous hypertension. There is increasing evidence that DVAs have a propensity for developing venous hypertension, which is thought to be the cause of associated cavernous malformations and parenchymal abnormalities.

CONCLUSIONS

DVAs represent variations of the normal cerebral venous angioarchitecture and by enlargement follow an uneventful clinical course. Complications can, however, occur and their management requires a thorough understanding of the nature of DVAs, including their frequent coexistence with other types of vascular malformation, and the existence of more complex but rare forms of presentation, such as the arterialized DVAs.

Ophthalmoplegic migraine: still a diagnostic dilemma?

The term ophthalmoplegic migraine (OM) was first coined by Charcot in 1890. This condition was included as a migraine variant in the first Headache Classification of the International Headache Society in 1988. Based on postcontrast enhancement seen on MRI in some patients who were diagnosed with OM, there was a suggestion that this could be an inflammatory/demyelinating disorder; therefore, it was moved out of the "migraine" group and repositioned as a "neuralgia" in the revised 2004 classification. However, there have been subsequent reports in the literature in which there was no enhancement on postcontrast MRI. Based on a survey of literature on OM in the post-imaging era, this article highlights the fact that enhancement on magnetic resonance is not a sine qua non for the diagnosis of OM. Some diagnostic dilemmas are discussed, and a protocol is included for documentation of clinical findings in future case reports on a prospective basis. Hopefully, this will help in modification of the criteria, better understanding the etiology, correct diagnosis, and determining appropriate treatment for OM.

Paralysies oculomotrices douloureuses : une approche diagnostique

We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.