Approach to ptosis Flashcards
What are the causes of unilateral ptosis?
CN 3
- Lone CN3 palsy: ischaemia, Pcomm A aneurysm
- Cavernous sinus syndrome
- Superior orbital fissure syndrome
- orbital apex syndrome
- midbrain lesion
- miller fischer syndrome
Myopathy
MG
Horner’s
- lateral medullary syndrome
- lateral pontine syndrome
- cervical/ T1 spine
- lung apical lesion
- ICA lesion
What are the causes of bilateral ptosis?
Myopathy
MG
CN3
- Midbrain lesion
- Miller fischer syndrome
What nerves are implicated in cavernous sinus syndrome?
Cavernous sinus – III, IV, V (V1,2), VI
What nerves are implicated in superior orbital fissure syndrome?
III, IV, V1, VI
What nerves are implicated in orbital apex syndrome?
II, III, IV, V (V1)
What are the central (1st order) cause of Horner’s syndrome?
Hypothalamus
- Stroke
- Tumor
- Brainstem (Lateral Medullary / pontine)
- Stroke
- Demyelination
- Tumor
Spinal Cord (Cervicothoracic)
- Trauma
- Tumor (Intermedullary)
- Myelitis
- Syringomyelia
- Demyelination
- AV Malformation
- nfarction
What are the preganglionic (2nd order) cause of Horner’s syndrome?
Pulmonary apical lesions
- Subclavian artery aneurysm
- Apical lung tumor (Pancoast)
- Mediastinal tumors
- Cervical rib
- Iatrogenic (jugular cannulation, chest tube, thoracic Sx)
Thyroid malignancies
What are the postganglionic (3rd order) cause of Horner’s syndrome?
Superior cervical ganglion
- Trauma
- Jugular venous ectasia
- Internal carotid artery Dissection (painful Horner’s)/ Aneurysm
- Trauma
- Arteritis
- Thrombosis
Skull base lesions: NPC, lymphoma
Cavernous sinus lesion
- Invasive pituitary tumor
- Inflammation
- Thrombosis
- Carotid aneurysm
What are the brainstem signs that suggest a brainstem localization?
diplopia, vertigo, ataxia, lateralized weakness
What are myelopathic features that suggest involvement of the cervicothoracic cord?
bilateral or ipsilateral weakness, long tract signs, sensory level, bowel and bladder impairment
What are the features that suggest a lesion in the lung apex?
Arm pain and/or hand weakness typical of brachial plexus lesions
What does an isolated Horner syndrome accompanied by neck or head pain?
internal carotid dissection.
What does ptosis + absence of anhidrosis suggest?
post-ganglionic horner syndrome
