8. Ellis SS, Montgomery JR, Wagner M, et al. Osteomyelitiscomplicating neonatal cephalhematoma. Am J Dis Child 1974;127:100–2.

9. Lee TJ, Berg RB. Cephalhematoma infected with Bacteroides. Am J

Dis Child 1971;121:77–8.10. Cohen SM, Miller BW, Orris HW. Meningitis complicating cephal-

hematoma. J Pediatr 1947;30:327–9.11. Harris VJ, Meeks W. The frequency of radiolucencies underlying

cephalhematomas. Radiology 1978;129:389–91.

12. Chan MCK, Boon WH. Infected cephalhematoma. J Sing Pediatr Soc

1972;14:57–60.13. Meignier M, Renaud P, Robert R, et al. Cephalhematoma infection

in neonatal septicemia. Pediatrics 1989;44:27–9.14. Lee PYC. Infected cephalhematoma and neonatal osteomyelitis. J

Infect 1990;21:191–3.15. Kao HC, Huang YC, Lin TY. Infected cephalohematoma associated

with sepsis and skull osteomyelitis: report of one case. Am J Perinatol

1999;16:459–62.

doi:10.1016/j.jocn.2005.08.018

Traumatic oculomotor nerve palsy

Takanobu Kaido a,*, Yoshihiro Tanaka a, Yukihide Kanemoto a,Yoshiaki Katsuragi b, Hisakazu Okura b

a Department of Neurosurgery, Nara Prefectural Gojo Hospital, Gojo, Nara, Japanb Department Ophthalmology, Nara Prefectural Gojo Hospital, Gojo, Nara, Japan

Received 26 May 2005; accepted 8 August 2005

Abstract

Traumatic isolated oculomotor nerve palsy is not common. Oculomotor nerve palsy without internal ophthalmoplegia (pupilsparing) is extremely rare. We report a case of this condition in a child. An 11-year-old boy was transferred to our hospital aftera head injury in a traffic accident. Neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, andinfraduction, incomplete convergence and left ptosis, but no internal ophthalmoplegia. Magnetic resonance imaging indicated mildbending of the ipsilateral oculomotor nerve at the posterior petroclinoid ligament. One month after injury, movement of thepatient’s eyes was normal on examination, but there was mild diplopia. The suggested mechanism of the oculomotor nerve palsywith pupil sparing in this case is stretching of the oculomotor nerve at the posterior petroclinoid ligament, maintaining an intactpupillomotor nerve.� 2006 Published by Elsevier Ltd.

Keywords: Oculomotor nerve palsy; Trauma; Posterior petroclinoid ligament

1. Introduction

Oculomotor nerve palsy generally causes mydriasis,impairment of eye adduction and upward and downwardgaze palsy in the affected eye.1 Isolated oculomotor nervepalsy, without other cranial nerve palsy is not common.2

This condition could possibly be caused by damage tothe ipsilateral oculomotor nerve by the posterior petrocli-noid ligament.3 There are, however, no previous reportssuggesting this mechanism. We report a patient with trau-matic isolated oculomotor nerve palsy, with magnetic reso-

nance imaging (MRI) providing evidence for thishypothesis.

2. Case report

An 11-year-old boy with no past medical history wasadmitted to hospital after a car accident. He had sustainedan injury to the left side of his face and the lateral supraor-bital region. On admission, he was vomiting, but was alert.There was no hemiparesis. His left superior palpebra was soswollen that it was difficult for him to open his left eye. Hisvisual acuity was intact, but he complained of horizontaland vertical diplopia. Both his pupils were 3 mm in diame-ter and reactive to light. X-rays of the skull and computedtomography (CT) of the brain and the skull were normal.

Two days after the injury, the swelling of the leftsuperior palpebra had reduced, but the left ptosis

* Corresponding author. Present address: Department of Neurosurgery,Musashi Hospital, National Center of Neurology and Psychiatry, Oga-wahigashi 4-1-1, Kodaira, Tokyo 187–8551, Japan. Tel.: +81 42 341 2711;fax: +81 42 346 1705.

E-mail address: kaido@ncnpmusashi.gr.jp (T. Kaido).

852 Case reports / Journal of Clinical Neuroscience 13 (2006) 852–855

remained. MRI indicated mild bending of the left oculo-motor nerve at the posterior petroclinoid ligament, butno abnormalities in the midbrain (Fig. 1). Examinationof ocular movements revealed limited left eye adduction,supraduction, and infraduction (Fig. 2). The left eye ab-ducted to the mid-position and there was limited conver-gence. A Hess screen chart examination revealed paresisof the left superior rectus, inferior oblique, and medialrectus muscles and overactivity of the right extraocularmuscles.

The patient was discharged from our hospital 5 daysafter injury. Four weeks after injury, the left side ptosishad improved and an ocular motility examination was nor-mal. A Hess screen chart examination also revealed no

paresis of the extraocular muscles, but mild diplopia re-mained. The patient was still being followed-up in our out-patient clinic at the time of writing.

3. Discussion

We report here a patient with isolated traumatic oculo-motor nerve palsy with pupil sparing. Heinz classified ocu-lomotor nerve injuries into three groups as follows: (1)avulsion of the oculomotor nerve rootlets; (2) focal stretch-ing in the parasellar segment; and (3) intraneural haemor-rhage at the superior orbital fissure.4 Otsuka andcolleagues5 suggested that lesions of the nerve in its intra-medullary portion, tentorial gap, intracavernous portion

Fig. 2. Examination of ocular movement 2 days after injury. Upper left: right supraduction; centre left: right lateral gaze; lower left: right infraduction;upper centre: supraduction; centre: mid-position; lower centre: infraduction; upper right: left supraduction; centre right: left lateral gaze; lower right: leftinfraduction.

Fig. 1. Right: axial T1-weighted MRI showing bending of the left oculomotor nerve at the posterior petroclinoid ligament, but no abnormalities in themidbrain. Left: anatomical drawing showing the same region in detail, reprinted with permission from – Pernkopf E. Atlas der topographischen undangewandten. Anatomie des Menschen. Vol. 1. Kopf und Hals. Urban and Fischer, Munich, Germany; 1987.28 Arrow, posterior petroclinoid ligament;arrowhead, oculomotor nerve.

Case reports / Journal of Clinical Neuroscience 13 (2006) 852–855 853

and intraorbital portion could cause traumatic oculomotornerve palsy. Midbrain haemorrhage may also potentiallycause traumatic oculomotor nerve palsy,1,6 however, thisdid not occur in the present patient.

Oculomotor nerve palsy without internal ophthalmo-plegia (pupil sparing) has been reported previously. Ittypically occurs in ischaemic lesions of the peripheralnerve, but rarely in traumatic lesions.7 Some non-trau-matic lesions can also cause oculomotor nerve palsy withpupil sparing, including intracranial aneurysm,8 midbrainstroke,9 dissection10 and occlusion11 of the internal caro-tid artery, brain tumor,12 and frontal sinus mucocoele.13

It has also been reported to occur spontaneously.14 Ocu-lomotor nerve palsy in these non-traumatic lesions iscaused by ischaemia of the nerve or damage to the centralpotion.

Pupil sparing in traumatic oculomotor nerve palsy hasbeen previously reported in association with subduralhaematoma.15–17 Oculomotor nerve palsy in these caseswas, however, due to the secondary injury associatedwith transtentorial herniation. Ing et al.7 reported threecases of pupil sparing among 31 cases of traumatic ocu-lomotor nerve palsy. One patient also had trochlear andabducens nerve palsies, and two had no other cranialnerve palsies, but none of these patients was describedin detail.

With a frontal blow, a rostrocaudal line of force is gener-ated, which runs parallel to the course of the oculomotornerve. Traction at points of fixation is liable to damage thenerve and provoke either intraneural haemorrhage orstretching.18 The posterior petroclinoid ligament is a candi-date structure for injuring the oculomotor nerve and causingoculomotor nerve palsy.19–23 Kerr and Hollowell24 notedthat the pupillomotor fibres lie along the dorsomedial andmedial aspects of the oculomotor nerve and have a graduallydescending course as they run between the brainstem and theexit of the nerve from the subarachnoid space. Thus, pupilsparing may depend on the association between the courseof the pupillomotor fibres and the petroclinoid ligament.

The pupillomotor nerve in our patient did not appear tobe injured as there was no internal ophthalmoplegia. MRIsuggested that the ipsilateral oculomotor nerve was focallyinjured with the posterior petroclinoid ligament as afulcrum.

The incidence of primary traumatic oculomotor palsy incraniocerebral trauma is 1.1–1.2%.5,19,25 Tokuno and col-leagues26 described 10 cases of primary oculomotor nervepalsy due to head injury. In their series, no patientrecovered completely from oculomotor nerve palsy. Theprognoses of patients with blepharoptosis, external oph-thalmoplegia and internal ophthalmoplegia were analysedseparately. Recovery rates were 78, 44 and 20%, respec-tively. Aberrant regeneration of the oculomotor nerve fol-lowing traumatic brain injury has been described,7,27 andtwo alternative mechanisms for ‘misdirection’ have beenproposed: ephaptic transmission and central synaptic re-organisation.27

4. Conclusion

We report a patient with isolated traumatic oculomotornerve palsy with pupil sparing. A review of the literatureand the MRI features of this patient suggest that the lesionwas caused by bending of the oculomotor nerve at the pos-terior petroclinoid ligament during trauma.

References

1. Mizushima H, Seki T. Midbrain hemorrhage presenting withoculomotor nerve palsy: case report. Surg Neurol 2002;58:417–20.

2. Richards BW, Jones Jr FR, Younge BR. Causes and prognosis in4,278 cases of paralysis of the oculomotor, trochlear, and abducenscranial nerves. Am J Ophthalmol 1992;113:489–96.

3. Mariak Z, Stankiewicz A. Cranial nerve II-VII injuries in fatal closedhead trauma. Eur J Ophthalmol 1997;7:68–72.

4. Heinz J. Cranial nerve avulsion and other neural injuries. Med J Aust

1969;2:1246–9.5. Otsuka SI, Yamazoe N, Kikuta K, et al. Study on cases with primary

traumatic oculomotor nerve palsy. Nippon Geka Hokan 1994;63:87–90, In Japanese.

6. Balcer LJ, Galetta SL, Bagley LJ, et al. Localization oftraumatic oculomotor nerve palsy to the midbrain exit siteby magnetic resonance imaging. Am J Ophthalmol 1996;122:437–9.

7. Ing EB, Sullivan TJ, Clarke MP, et al. Oculomotor nerve palsies inchildren. J Pediatr Ophthalmol Strabismus 1992;29:331–6.

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14. Blumen SC, Feiler-Ofry V, Korczyn AD. Does pupillary sparingoculomotor nerve palsy really spare the pupil? J Clin Neuroophthalmol

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sparing in a patient with chronic subdural hematoma. Surg Neurol

1985;24:668–70.16. Keane JR. Oculomotor palsy with pupillary sparing in subdural

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palsy from acute subdural hematoma. Ann Ophthalmol 1984;16:387–90.

18. Kruger M, Noel P, Ectors P. Bilateral primary traumatic oculomotornerve palsy. J Trauma 1986;26:1151–3.

19. Memon MY, Paine KW. Direct injury of the oculomotor nerve incraniocerebral trauma. J Neurosurg 1971;35:461–4.

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20. Cross AG. The ocular sequelae of head injury. Ann Roy Coll Surg Eng

1948;2:233–40.21. Geraud J, Ribaut L, Rascol A. Considerations cliniques sur quelques

cas de paralysies oculo-motrices secondaires a un traumatismecranien. Rev Otoneuroophtalmol 1964;36:97–101.

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Shinkei Geka 1977;5:1065–9, In Japanese.23. Nagaseki Y, Shimizu T, Kakizawa T, et al. Primary internal ophthal-

moplegia due to head injury. Acta Neurochir (Wien) 1989;97:117–22.24. Kerr FW, Hollowell OW. Location of pupillomotor and accom-

modation fibers in the oculomotor nerve: Experiment observations

on paralytic mydriasis. J Neurol Neurosurg Psychiatry 1964;27:473–81.

25. Solomons NB, Solomon DJ, de Villiers JC. Direct traumatic thirdnerve palsy. S Afr Med J 1980;58:109–11.

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doi:10.1016/j.jocn.2005.08.020

Intracranial sewing needle

Kagan Tun *, Erkan Kaptanoglu, O. Faruk Turkoglu, R. Cengiz Celikmez, Ethem Beskonakli

Department of Neurosurgery, Ankara Numune Education and Research Hospital, Ankara, Turkey

Received 17 March 2005; accepted 1 June 2005

Abstract

A 45-year-old patient was found to have an intracranial sewing needle, located in the left frontal lobe. The needle was detected inci-dentally after minor head trauma. The clinical and radiological findings suggested that it might have entered the brain through the ante-rior fontanelle.� 2006 Elsevier Ltd. All rights reserved.

Keywords: Brain; Sewing needle; Foreign body; Radiography

1. Introduction

Intracranial foreign bodies are usually secondary to pe-netrating head trauma and surgical procedures.1,2 Penetrat-ing trauma secondary to gunshot wounds are a commoncause of injury in neurosurgical practice. Penetrating cra-niocerebral injuries from objects such as needles, iron rods,pieces of wood and nails, however, are rare.3 Another rarecause is insertion of a foreign body through the anteriorfontanelle in attempted infanticide.4 We report the caseof a 45-year-old patient with an intracranial sewing needle,an interesting condition that was not noticed by the patientor his relatives.

2. Case report

A 45-year-old male patient was referred to our hospitalby an emergency service with a minor head injury after acar accident. A neurological examination was entirely nor-mal except for abrasion at the right frontal region. Cranialradiography was requested to rule out the possibility offracture. A sewing needle in the left frontal region of thebrain was seen in X-rays (Fig. 1A,B). A computed tomog-raphy (CT) scan showed that the needle was in the leftfrontal lobe, close to the anterior horn of the left lateralventricle. No signs of intracranial bleeding were detectedby the CT scan (Fig. 2). The patient stated that he didnot know how the needle came to be placed there. His rel-atives and friends were also unable to provide any informa-tion. The location and position of the sewing needleconvincingly suggests that it might have been insertedthrough the anterior fontanelle when the patient was an in-fant. The patient was not epileptic. Surgical interventionwas considered unnecessary and potentially hazardous,

* Corresponding author. Present address: Hilal mah. 65. sok. No. 9/606550 Cankaya, Ankara, Turkey. Tel.: +90 312 4414087; fax: +90 3124401268.

E-mail address: kagantun@yahoo.com (K. Tun).

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