Neuro-ophthalmic Analyses of Head Trauma Patients

Hun Min Kim; Dae Hyun Kim

doi:10.3341/jkos.2019.60.11.1105

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Kim and Kim: Neuro-ophthalmic Analyses of Head Trauma Patients

Original Article

J Korean Ophthalmol Soc 2019;60(11):1105-1111.

Published online: 25 September 2019

DOI: https://doi.org/10.3341/jkos.2019.60.11.1105

Neuro-ophthalmic Analyses of Head Trauma Patients

Hun Min Kim, 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 61453, Korea Tel: 82-62-220-3190, Fax: 82-62-225-9839 E-mail: eyelovehyun@hanmail.net

Received 16 May 2019 Revised 22 May 2019 Accepted 23 October 2019

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 investigate the types and clinical features of neurological diseases after head trauma.

Methods

From March 2010 to December 2018, a total of 177 patients were enrolled in this study. We retrospectively reviewed the clinical features of neurological ophthalmic diagnoses and frequencies, the types of head injuries, and the prognoses.

Results

Cranial nerve palsy was the most common (n = 63, 35.6%), followed by traumatic optic neuropathy (n = 45, 25.4%), followed by optic disc deficiency, ipsilateral visual field defect, Nystagmus, skewing, ocular muscle paralysis between nuclei, and Terson syndrome. Neuro-ophthalmic deficits occurred in relatively strong traumas accompanied by intracranial hemorrhage or skull fracture. However, convergence insufficiency and decompensated phoria occurred in relatively weak trauma such as concussion. The prognoses of the diseases were poor (p < 0.05) for traumatic optic neuropathies and visual field defects. The prognoses of neurological diseases were poor if accompanied by intracranial hemorrhages or skull fractures (p < 0.05).

Conclusions

After head trauma, various neuro-ophthalmic diseases can occur. The prognosis may differ depending on the type of the disease, and the strength of the trauma may affect the prognosis.

Keywords: Cranial nerve paralysis, Head trauma, Neuro-ophthalmic diseases

References

1. Felleman DJ, Van Essen DC. Distributed hierarchical processing in the primate cerebral cortex. Cereb Cortex. 1991; 1:1–47.

2. Kim SS, Jin KH, Kim SM. Neuro-ophthalmologic evaluation of the third, fourth and sixth cranial nerve paralysis. J Korean Ophthalmol Soc. 1991; 32:283–8.

3. Jeong JS, Kim DH. Associated injuries and prognosis in traumatic isolated 3rd, 4th, and 6th cranial nerve palsies. J Korean Ophthalmol Soc. 2014; 55:596–601.

4. Park JW, Jeong SK, Park YG. Clinical evaluation of the traumatic optic neuropathy. J Korean Ophthalmol Soc. 1999; 40:3497–505.

5. Shin GR, Kim DH. Clinical manifestations and prognosis of abdominal with traumatic optic neuropathy. J Korean Ophthalmol Soc. 2016; 57:1770–6.

6. Sabates NR, Gonce MA, Farris BK. Neuro-ophthalmological abdominal in closed head trauma. J Clin Neuroophthalmol. 1991; 11:273–7.

7. Keane JR. Neurologic eye signs following motorcycle accidents. Arch Neurol. 1989; 46:761–2.

8. Kowal L. Ophthalmic manifestations of head injury. Aust N Z J Ophthalmol. 1992; 20:35–40.

9. Lepore FE. Disorders of ocular motility following head trauma. Arch Neurol. 1995; 52:924–6.

10. Moster M, Vope N, Kresloff M. Neuro-ophthalmologic findings in closed head injury. Neurology. 1999; 52:A23.

11. Van Stavern GP, Biousse V, Lynn MJ, et al. Neuro-ophthalmic manifestations of head trauma. J Neuroophthalmol. 2001; 21:112–7.

12. Lee DW. Neuro-ophthalmic manifestations of head trauma and predictive factors. J Korean Ophthalmol Soc. 2005; 46:422–8.

13. Rucker CW. The causes of paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol. 1966; 61(5 Pt 2):1293–8.

14. Imachi J. Clinical and pathohistological investigations of optic nerve lesions in cases of head injuries. Jpn J Ophthalmol. 1968; 12:70–85.

15. Ventura RE, Balcer LJ, Galetta SL. The neuroophthalmology of head trauma. Lancet Neurol. 2014; 13:1006–16.

16. Shin MH, Kim DH. Clinical manifestations and prognosis of abdominal insufficiency after craniofacial trauma. J Korean Ophthalmol Soc. 2015; 56:1604–9.

17. Cohen M, Groswasser Z, Barchadski R, Appel A. Convergence abdominal in brain-injured patients. Brain Inj. 1989; 3:187–91.

18. Perunovic B, Quilty RD, Athanasiou A, Love S. Damage to abdominal optic pathways in fatal closed head injury in man. J Neurol Sci. 2001; 185:55–62.

19. Keane JR. Internuclear ophthalmoplegia: unusual causes in 114 of 410 patients. Arch Neurol. 2005; 62:714–7.

20. Brahm KD, Wilgenburg HM, Kirby J, et al. Visual impairment and dysfunction in combat-injured servicemembers with traumatic brain injury. Optom Vis Sci. 2009; 86:817–25.

21. Goodrich GL, Flyg HM, Kirby JE, et al. Mechanisms of TBI and visual consequences in military and veteran populations. Optom Vis Sci. 2013; 90:105–12.

22. Dhaliwal A, West AL, Trobe JD, Musch DC. Third, fourth, and sixth cranial nerve palsies following closed head injury. J Neuroophthalmol. 2006; 26:4–10.

Table 1.

Causes of traumatic brain injury

Cause of injury	Patients with neuro-opphthalmic deficit (n = 177)
Motor vehicle accident	86 (48.6)
Motorcycle accident	23 (13.0)
Fall	26 (14.7)
Violence	17 (9.6)
Sports injury	14 (7.9)
Unknown	11 (6.2)

Values are presented as number (%).

Table 2.

Frequency of neuro-ophthamic deficit

Deficit	Patients with neuro-opphthalmic deficit (n = 177)
Traumatic optic neuropathy	45 (25.4)
Homonymous visual field defect	12 (6.8)
Terson syndrome	2 (1.1)
3rd nerve palsy	15 (8.5)
4th nerve palsy	29 (16.4)
6th nerve palsy	19 (10.7)
Convergence insufficiency	15 (8.5)
Skew/nystagmus	5 (2.8)
INO	2 (1.1)
Decompensated phoria	10 (5.6)
Decompensated XT	2 (4.0)
Decompensated ET	1 (0.6)
SOP	7 (1.7)
Combined injury^*	23 (13.0)

Values are presented as number (%). INO = internuclear ophthalmoplegia; SOP = superior oblique pal-sy; XT = exotropia; ET = esotropia.

^* Patients who had multiple deficit that contain bilateral ocular injury.

Table 3.

Demographics of neuro-ophthalmic patient

Characteristic	TON (n= 45)	Visual field defect (n = 12)	Terson syndrome (n = 2)	3rd nerve palsy (n = 15)	4th nerve palsy (n = 29)	6th nerve palsy (n = 19)	Converg ence insufficie ncy (n = 15)	Nystagm us/ skew (n = 5)	INO (n= 2) D	Decompensa ted phoria (XT, ET, SOP) (n = 10)	a Combined injury^* (n = 23)
Mean age (years, range)	44.5 (9–78)	48.6 (27–61)	40.0 (35–45)	47.0 (23–70)	46.2 (11–69)	38.2 (11–82)	36.2 (14–62)	42.5 (14–55)	53 (51–55)	48.3 (14–62)	55.7 (14–82)
Sex
Male	39 (86.7)	8 (66.7)	1 (50)	11 (73.3)	20 (69.0)	14 (73.7)	10 (66.7)	4 (80)	2 (100)	8 (80)	20 (86.9)
Female	6 (13.3)	4 (33.3)	1 (50)	4 (26.7)	9 (31.0)	5 (26.3)	5 (33.3)	1 (20)	0	2 (20)	3 (13.0)
Durataion to 1st exam (weeks)	6.9 ± 2.3	16.2 ± 1.5	12.1 ± 3.4	9.0 ± 5.4	13.3 ± 3.2	7.8 ± 5.6	15.7 ± 3.1	8.2 ± 4.2	7.1 ± 5.3	7.8 ± 2.3	14.5 ± 3.6
Total observed time (weeks)	25.5 ± 14.3	34.4 ± 13.2	23.2 ± 12.1	34.5 ±13.5	39.5 ± 17.5	36.4 ± 16.8	27.1 ± 12.1	27.7 ± 14.2	24.4 ± 10.2	28.3 ± 12.4	4 36.2 ± 15.8

Values are presented as mean ± standard deviation or number (%) unless otherwise indicated.

TON = traumatic optic neuropathy; INO = internuclear ophthalmoplegia; SOP = superior oblique palsy.

^* Patients who had multiple deficit that contain bilateral ocular injury.

Table 4.

Type of traumatic brain injury in patients with neuro-ophthalmic deficit

Variable	TON (n = 45)	Visual field defect (n = 12)	Terson syndrome (n = 2)	3rd nerve palsy (n = 15)	4th nerve palsy (n = 29)	6th nerve palsy (n = 19)	Converg ence insufficie ncy (n = 15)	Nystagm us/skew (n = 5)	INO (n = 2)	Decompensa ted phoria (XT, ET, SOP)(n = 10)	Combined injury^*(n = 23)
Loss of consciousness	40 (88.9)	4 (33.3)	1 (50.0)	12 (80)	12 (41.4)	6 (31.6)	8 (53.3)	5 (100.0)	1 (50.0)	1 (10.0)	19 (82.6)
Intracranial hemorrhage^†	31 (68.9)	8 (66.7)	0	14 (93.3)	7 (24.1)	4 (21.1)	7 (46.7)	5 (100.0)	2 (100.0)	3 (30.0)	20 (87.0)
Cranial bone fracture^‡	12 (26.7)	7 (58.3)	0	11 (73.3)	9 (31.0)	10 (52.6)	8 (53.3)	4 (80.0)	1 (50.0)	2 (20.0)	11 (47.8)
Concussion	6 (13.3)	0	1 (50.0)	2 (13.3)	7 (24.1)	4 (21.1)	6 (40.0)	0	0	7 (70.0)	0

Values are presented as number (%).

^* Patients who had multiple deficit that contain bilateral ocular injury

^† subdural, epidural, intracranial, subarachnoid, intraventricular

^‡ temporal, occipital, frontal, skull base.

Table 5.

Comparison of neuro-ophthalmic deficit between the recovered group and the persistent group

Characteristic	Recovered group (n = 65)	Persistent group (n = 112)	p-value^*
Traumatic optic neuropathy	11	34	0.048
Visual field defect	5	7	0.761
Terson syndrome	1	1	1.000
3rd nerve palsy	2	13	0.049
4th nerve palsy	15	14	0.024
6th nerve palsy	11	8	0.021
Convergence insufficiency	7	8	0.414
Skew/nystagmus	1	4	0.653
INO	0	2	0.533
Decompensated phoria	2	8	0.329
Combined injury	5	18	0.061

INO = internuclear ophthalmoplegia.

^* Pearson's chi-square test.

Table 6.

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

Characteristic	Recovered group (n = 65)	Persistent group (n = 112)	p-value^*
Loss of consciousness	40	68	0.127
Intracranial hemorrhage^†	29	72	0.011
Cranial bone fracture^‡	21	54	0.039
Concussion	15	18	0.249

^* Pearson's chi-square test

^† subdural, epidural, intracranial, subarachnoid, intraventricular

^‡ temporal, occipital, frontal, skull base.

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