【摘要】目的：了解头颅外伤患者眼运动神经麻痹的情况。方法：收集200603/200609 Shahid Rahnemon医院神经外科收治的300名头颅外伤患者的资料，包括眼科检查和调查问答，采用SPSS软件卡方和F检验进行数据分析。结果：300例患者中242例为男性（81.1%），58例为女性(18.9%)，年龄为1～87（平均46）岁。意外跌伤是头部外伤最常见的原因，共247例患者(82.3%)因此致伤；大多数患者的GCS得分为13～15（82.3%）。最多见的颅脑外伤为硬膜下腔、蛛网膜下腔出血。滑车神经或外展神经麻痹（28.6%）、其他眼运动神经麻痹或同时两处眼运动神经麻痹（常见第3颅神经和第4颅神经麻痹，14.3%）是最常出现的情况。结论：虽然头颅外伤同时出现颅神经麻痹的几率较小，但是在急诊时应根据情况进行神经眼科检查。
【关键词】 头颅外伤；眼运动神经麻痹；滑车神经麻痹；外展神经麻痹
AbstractAIM: To determine ocular motor nerve palsy in patients with head trauma.METHODS: There were three hundred admitted cases of head trauma in neurosurgery department of Shahid Rahnemon Hospital from March 2006 to September 2006. Data were collected with ophthalmic examinations, filled in questionnaires and analyzed by SPSS software statistically including Chisquare test and Fishers exact test.RESULTS: A total of 300 patients were reviewed, 242 (81.1%) men and 58 (18.9%) women. Their age ranged from 1 to 87 years (mean of 46 years). Accident and fall were the most common causes of head trauma, occurring in 247 (82.3%) patients and most of patients had Glasgow Coma Scale (GCS) 1315(82.3%). The most cerebral lesion was subdural and subarachnoid hematoma. Isolated trochlear and abducens nerve palsy (28.6%), isolated oculomotor nerve and combined nerve palsies (combination of 3rd and 4th cranial nerves, 14.3%) were the most affected nerves.CONCLUSION: Although the cranial nerve palsy is rare with minor head trauma, according to their observation in emergency room, neuroophtalmic examination is advised.
KEYWORDS: head trauma; oculomotor nerve palsy; trochlear nerve palsy; abducens nerve palsy
INTRODUCTION
Traumatic head injury (THI) plays a significant role in rehabilitation and public health[1]. It has been referred to as the "silent epidemic" because of its vast incidence and pressing need for additional research[2,3] . Falls, motor vehicle traffic (MVT) accidents, and assaults were the leading contributors to THIrelated hospitalizations[4]. Strict criteria allow for classification of head injury as mild, moderate, and severe[5]. Mild THI was defined by the Glasgow Coma Scale (GCS) score of 13 or more, and posttraumatic amnesia lasting less than 24 hours[5,6]. Palsy of cranial nerve 3 is usually associated with severe head trauma[7,8] with poor prognosis, especially in complete palsy with a high incidence of traumatic subarachnoid hemorrhage or skull fractures[9,10]. Traumatic palsy of both oculomotor nerves is rare[11]. Palsy of trochlear nerve in a relatively mild head trauma as the principal cause occurs more than inflammation and brain tumors[12,13]. Even a minor occipital impact or direct impact force toward the tentorium with compression, contusion or avulsion of the trochlear nerve can cause it[1417]. The abducens nerve is particularly vulnerable to traumatic injury because of its long tortuous route from cranial nerve nucleus to the lateral rectus muscle[18]. With respect to the incidence of sixth nerve palsy (11.3 in 100 000)[19], unilateral abducens palsy occurred in 1%2.7% of patients with head trauma and bilateral traumatic abducens nerve palsy even occurred rarely[18,2022], resulting in esotropia greater in distance and ipsilateral abduction deficiency[18]. We decided to survey the cranial nerve palsies resulting from head trauma in Yazd city because of traffic accident frequency and lack of information.
MATERIALS AND METHODS
We reviewed 300 patients (242 male and 58 female) between 1 and 78 (average 46) years admitted from March 2006 to September 2006 in Neurosurgery Department of Shahid Rahnemon Hospital. After patients were stabilized and hospitalized in neurosurgery wards, in the first few hours the information about age, gender, Glasgow Coma Scale (GCS) level, documented loss of consciousness (LOC), cognitive scores, cause of trauma , presence of systemic injury and imaging features was provided. Results of ocular examinations were recorded by an ophthalmologist. Statistical data were analyzed by SPSS software, including Chisquare test and Fishers exact test.
RESULTS
Among 300 cases, the majority of them (242 cases, 81.1%) were male and 58 cases (18.9%) were female. Their age ranged 178 years (average 46 years) with majority of them aged 114 years. Head trauma most frequently occurred by accidents (247 cases, 82.3%), falls (38 cases, 12.7%) and assaults (4 cases, 1.4%). Most of patients had GCS 1315 (264 cases, 88.0%), 28 cases (9.3%) had GCS 912 and 8 cases (2.6%) had GCS<8.
Subdural hematoma, subarachnoid hematoma and brain edema were the most cerebral lesions (17 cases, 24.3%); epidural hematoma (17.1%) and brain contusion (10.0%) were the next frequent lesions.
Among 7 persistent paralytic ocular motor nerve palsies, palsies of the trochlear nerve (2 cases, 28.6%) and the abducens nerve (2 cases, 28.6%) were more frequent than oculomotor nerve (1 case, 14.3%). Combined ocular nerve palsies (2 cases, 28.6%) were generally combinations of the 3rd and 4th cranial nerves (1 case, 14.3%) or pareses of all three ocular nerves (1 case, 14.3%) .
Frequently associated lesions were respectively eyelid injuries (15 cases, 88.2%) and orbital injuries (2 cases, 11.8%).
DISCUSSION
Head trauma causes a number of neuroophtalmic manifestations such as ocular motor nerve palsies[23]. To determine the type and frequency of this complication, we analyzed 300 cases of head trauma. The affected male /female ratio in our study was 4.2∶1, which has been reported in several similar studies. In the study of Van Stavern et al[23], findings in a group of patients with head trauma showed that the male/female ratio was 1.65∶1, the study by Pelletier et al[24] showed it was 4.3∶1, while in a study by KubatkoZielinskaet al [25]it was 2.3∶1.
Range of patients age was 178 years old (mean of 46 years old). Mean age of 326 head trauma patients during 19911999 was 30 years old[23], which is near to mean age of our patients. These studies show that the most victims of traumatic head injury are juvenile and adult age group.
Trauma was the most common reason for acquired cranial nerve palsy in their pediatric group of Kodsi and Younge[26] study. The rate of patients with an traumatic acquired cranial nerve palsy was significantly greater in the pediatric group (42.5%) than in adults (15.4%). It was similar to our study in which most injured age was pediatric group with age range of 1 to 14 years.
The most leading causes were accidents (82.3%), falls(12.7%) and assaults (1.4%) in the report from Centers for Disease Control and Prevention of 12 states. Falls, motor vehicle traffic (MVT) accidents, and assaults were the leading contributors to THIrelated hospitalizations[4]. These are similar to the most frequent causes in KubatkoZielinska et al[25]study (traffic accidents 37.5%, assaults 21.7%) , Simsek et al[27] study (falls 34.3%) and Kulkarni et al[28]study (road traffic accidents 52.5%, assaults 34%).
To classify severity of head trauma in patients according to Glasgow Coma Scale (GCS), the majority of patients had minor to mild head trauma with GCS 1315 (88.5%), whereas moderate head trauma with GCS 912 occurred in 9.2% and severe head trauma with GCS≤8 occurred in 2.3% of patients. These results were near to those of a study by Simsek et al [27]on 280 cases between 1995 and 2004. The patients had minor (70.1%), moderate (17.1%), and severe (6.8%) head injuries. But from the study of Dacey et al [29]on 610 patients who had sustained a transient posttraumatic unconsciousness or other neurological dysfunction, GCS was 1315 in the emergency room. It can be drawn that an initial GCS 1315 does not necessarily indicate that a patient has sustained a trivial head injury, since 3% of such patients will require an operative procedure despite an initially normal level of alertness. It is very unusual for patients who have a GCS score of 15 and a normal skull xray film to have a significant neurosurgical complication [29], but some rare reports such as Chen et al [7]report described cranial nerve palsies without initial loss of consciousness and normal CT, MRI, and MRA.
The development of modern imaging techniques has significantly improved the diagnosis of disorders affecting the ocular motor nerves[30]. CT can provide indirect evidence of injuries to the optic and oculomotor nerves, but MRI as the most important diagnostic tool in most cases has been confirmed[31]. There is no consistent association between the location of imaging abnormalities and which cranial nerve was damaged[8].
In light of the less frequency of brain contusion in comparison with high presentation of subdural hematoma, subarachnoids hematoma, brain edema and also less frequency of severe head trauma in our study, clinical and pathological findings of a post term study on 20 specimens were provided by 10 autopsy cases due to severe head trauma. Edema and hemorrhagic contusion were observed in all brains in microscopic sections[32].
Müri et al[15]analyzed 39 cases with isolated trochlear nerve palsies of traumatic origin. 46% had cerebral contusion, 39% cerebral concussion, and 15% a minor head trauma. 33 patients had unilateral and 6 had bilateral trochlear nerve palsies. The degree of the palsies was not correlated with the severity of the head trauma and isolated trochlear nerve palsies were observed in 21 of 39 (54%) patients. Essential pathogenic mechanisms were frontal or occipital blows that are similar to main cause of four patients with transient trochlear nerve palsy in the Hoya et al [14]study.
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