Associated Injuries and Prognosis in Traumatic Isolated 3rd, 4th, and 6th Cranial Nerve Palsies

Ji Seong Jeong; Dae Hyun Kim

doi:10.3341/jkos.2014.55.4.596

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Jeong and Kim: Associated Injuries and Prognosis in Traumatic Isolated 3rd, 4th, and 6th Cranial Nerve Palsies

Original Article

J Korean Ophthalmol Soc 2014;55(4):596-601.

Published online: 7 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.4.596

Associated Injuries and Prognosis in Traumatic Isolated 3rd, 4th, and 6th Cranial Nerve Palsies

Ji Seong Jeong, MD, Dae Hyun Kim, MD, PhD

Department of Ophthalmology, Chosun University College of Medicine, Gwangju, Korea

Address reprint requests to Dae Hyun Kim, MD, PhD Department of Ophthalmology, Chosun University Hospital, #365 Pilmun-daero, Dong-gu, Gwangju 501-717, Korea, Tel: 82-62-220-3190, Fax: 82-62-225-9839 E-mail: eyekim@chosun.ac.kr

Received 8 July 201313 October 2013 Accepted 17 February 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To analyze the relationship between prognosis and the severity of associated injuries in traumatic isolated 3rd, 4th and 6th cranial nerve palsies.

Methods

The records of 39 patients (39 eyes) who were diagnosed with isolated 3rd, 4th or 6th cranial nerve palsy following trauma were reviewed retrospectively to analyze the etiology of trauma, the degree of associated injuries, the degree of paralysis, and the prognosis.

Results

The 4th cranial nerve was affected most frequently (19 patients, 48.7%), followed by the 6th nerve (12 patients, 30.8%) and the 3rd nerve (8 patients, 20.5%). Traffic accidents were the most frequent etiology of traumatic cranial nerve palsies. Loss of consciousness, intracranial hemorrhage, craniofacial fracture, c-spine injury, and optic nerve injury were among the most common accompanying conditions. The 3rd cranial nerve was the most severely paralyzed and showed the highest number of associated injuries. The recovery rate of the all cranial nerve palsies was 46.2%. By nerve, the 3rd cranial nerve palsy showed the lowest recovery rate of 25%, followed by the 4th nerve at 47.4%, and the 6th nerve at 58.3%.

Conclusions

The prognosis was worse in patients with intracranial hemorrhage, compared with those without intracranial hemorrhage. There was a higher average number of associated injuries and the degree of paralysis was more severe in 3rd nerve palsies.

Keywords: Cranial nerve palsy, Intracranial hemorrhage, Trauma

References

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Table 1.

Distribution of patients with cranial nerve palsy by age, sex, and etiology

		3rd Nerve	4th Nerve	6th Nerve	Total	p-value
Number (%)		8 (20.5)	19 (48.7)	12 (30.8)	39 (100)
Mean age (years)		50.4 ± 19.0	53.0 ± 10.9	48.0 ± 25.9	51.0 ± 17.8	0.946^*
Sex	Male (%)	6	14	8	28 (71.8)
	Female (%)	2	5	4	11 (18.2)
Etiology	Traffic accident (%)	7 (87.5)	15 (78.9)	6 (50.0)	28 (71.8)
	Fall down (%)	1 (12.5)	4 (21.1)	6 (50.0)	11 (18.2)
Duration to 1st exam (weeks)		10.0 ± 2.1	12.2 ± 14.5	8.5 ± 2.6	10.6 ± 10.2	0.429^*
Total observed time (weeks)		78.2 ± 14.4	58.7 ± 20.0	61.8 ± 26.5	63.9 ± 22.3	0.094^*

Values are presented as mean ± SD.

^* Kruskal-wallis test among the each cranial palsy group.

Table 2.

Frequency of the Associated injury according to cranial nerve palsy

Associated injury 3	3rd Nerve (n = 8)	4th Nerve (n = 19)	6th Nerve (n = 12)	Total (n = 39)	p-value
Loss of consciousness (%)	8 (100)	9 (47.4)	7 (58.3)	24 (61.5)	0.026^‡
C-spine injury (%)	1 (12.5)	4 (21.1)	4 (33.3)	9 (23.1)	0.689^‡
Intracranial hemorrhage^* (%)	6 (75.0)	9 (47.4)	3 (25.0)	18 (46.2)	0.092^‡
Craniofacial fracture^† (%)	6 (75.0)	6 (31.6)	6 (50.0)	18 (46.2)	0.134^‡
Optic nerve injury (%)	2 (25.0)	0 (0)	0 (0)	2 (5.1)	0.038^‡
Average number of associated injury	2.9 ± 1.0	1.5 ± 1.4	1.7 ± 1.2	1.8 ± 1.4	0.043^‡

Values are presented as mean ± SD.

^* Intracranial hemorrhage: Subdural, Epidural, Intracranial, Subarachnoid, Intraventricular

^† Craniofacial fracture. : Temporal, Occipital, Frontal, Skull base, Maxillozygoma, Orbital wall fx.

^‡ Pearson's Chi-square test.

Table 3.

Location of intracranial hemorrhage by cranial nerve palsy groups

	3rd Nerve (n = 8)	4th Nerve (n = 19)	6th Nerve (n = 12)	Total (n = 39)
Frontal area (%)	2 (25.0)	6 (31.6)	1 (8.3)	9 (23.1)
Temporal area (%)	6 (75.0)	5 (26.3)	2 (16.7)	13 (33.3)
Parietal area (%)	1 (12.5)	2 (10.5)	2 (16.7)	5 (12.8)
Occipital area (%)	0 (0)	2 (10.5)	1 (8.3)	3 (7.7)
Cerebellum (%)	0 (0)	0 (0)	2 (16.7)	2 (5.1)
Basal ganglia (%)	0 (0)	1 (5.3)	0 (0)	1 (5.1)

Table 4.

Distribution of the craniofacial fracture by cranial nerve palsy groups

	3rd Nerve (n = 8)	4th Nerve (n = 19)	6th Nerve (n = 12)	Total (n = 39)
Temporal bone fx. (%)	6 (75.0)	2 (10.5)	3 (25.0)	11 (28.2)
Frontal bone fx. (%)	0 (0)	3 (15.8)	1 (8.3)	4 (10.3)
Skull base fx. (%)	0 (0)	0 (0)	3 (25.0)	3 (7.7)
Parietal bone fx. (%)	0 (0)	1 (5.3)	0 (0)	1 (2.6)
Occipital bone fx. (%)	1 (12.5)	2 (10.5)	3 (25.0)	6 (15.4)
Maxillozygoma fx. (%)	1 (12.5)	3 (15.8)	2 (16.7)	6 (15.4)
Orbital wall fx. (%)	1 (12.5)	2 (10.5)	1 (8.3)	4 (10.3)

Table 5.

Degree of paralysis, recovery rate between each cranial nerve palsies

	3rd Nerve	4th Nerve	6th Nerve	Total	p-value
Deviation angle at 1st exam (PD)	38.1 ± 7.5^*	13.8 ± 3.4^†	34.8 ± 14.3^*	25.3 ± 14.3	0.678^∏
EOM limitation at 1st exam	-3.5 ± 0.5^‡	1.2 ± 0.6^§	-2.6 ± 1.6^‡	-1.0 ± 2.3	0.305^∏
Recovery group (%)	2/8 (25.0)	9/19 (47.4)	7/12 (58.3)	18/39 (46.2)	0.339^＃
Persistent group (%)	6/8 (75.0)	10/19 (52.6)	5/12 (41.7)	21/39 (53.8)	0.462^＃

Values are presented as mean ± SD.

PD = prism diopter; EOM = extraocular muscle.

^* Horizontal deviation angle

^† Vertical deviation angle

^‡ Horizontal movement limitation

^§ Inferior oblique overaction

^∏ Kruskal-wallis test, Between 3rd nerve and 6th nerve

^＃ Pearson's Chi-square test among the each cranial palsy group.

Table 6.

Comparison of the associated injury between the recovered group and the persistent group

	Recovered group	Persistent Group	p-value
Loss of consciousness	9/18	15/21	0.203^‡
Optic nerve injury	0/18	2/21	0.490^‡
C-spine injury	2/18	7/21	0.139^‡
Deviation angle at 1st exam (PD)	20.5 ± 12.2	30.7 ± 14.8	0.060^§
EOM Limitation at 1st exam	-0.6 ± 1.8	-1.2 ± 2.7	0.728^§
Intracranial hemorrhage^*	4/18	14/21	0.010^‡
Craniofacial fracture^†	6/18	12/21	0.201^‡
Average number of associated injury	1.2 ± 1.2	2.4 ± 1.3	0.006^§

Values are presented as mean ± SD.

PD = prism diopter; EOM = extraocular muscle.

^* Intracranial hemorrhage: Subdural, Epidural, Intracranial, Subarachnoid, Intraventricular

^† Craniofacial fracture: Temporal, Occipital, Frontal, Skull base, Maxillozygoma, Orbital wall fx.

^‡ Pearson's Chi-square test

^§ Mann-Whitney test.

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