뇌조조영술 후 발생한 양측 활차신경마비 1예
A Case of Bilateral Trochlear Nerve Palsy Following Cisternography
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목적: 뇌조조영술 후 발생한 양측 활차신경마비 1예를 경험하였기에 이를 보고하고자 한다. 증례요약: 43세 남자가 3개월간의 간헐적인 맑은 코분비물을 주소로 신경외과에 내원하였다. 과거력 상 22년 전에 뇌하수체선종 제거술을 받았다. 뇌척수액 누출이 의심되어 뇌조조영술을 시행하였고, 3일 후 복시를 호소하여 안과로 의뢰되었다. 교대프리즘가림검사상 제일눈위치에서 5프리즘디옵터의 우안 상사시를 보이며 양안의 상사근기능저하와 좌안의 하사근기능항진이 관찰되었다. 빌쇼스키머리기울임검사에서 양측으로 모두 양성이었고, 이중마독스막대검사에서 9° 외회선이 나타나 양측 활차신경마비로 진단되었다. 경과관찰 2년 후에도 복시가 지속되어 양안 하사근 후전술을 시행하였다. 수술 후 복시는 소실되었으며 안저검사상 외회선은 관찰되지않았고, 이중마독스막대검사상 외회선은 3°로 나타났다. 결론: 뇌조조영술 시행 후 매우 드물게 양측 활차신경마비가 발생할 수 있으므로 주의하여야 한다.
Abstract
Purpose: To report a case of bilateral trochlear nerve palsy following cisternography. Case summary: A 43-year-old male with intermittent watery rhinorrhea persisting for 3 months visited the neurosurgery departmentof our institute. His past medical history included removal of a pituitary adenoma 22 years prior to presentation. Cerebrospinal fluid leakage was suspected and cisternography was performed. The patient was referred to our ophthalmologydepartment for diplopia 3 days after the cisternography. An alternate prism cover test showed 5 prism diopter(PD) right hypertrophia in the primary position, and underaction of bilateral superior oblique muscles and overaction of theleft inferior oblique muscle. A positive Bielschowsky test with the head tilted to either side was observed and excyclotorsionwas 9° on the double Maddox rod test. The patient was diagnosed with bilateral trochlear nerve palsy. After 2 years of follow-up, diplopia persisted and recession of the bilateral inferior oblique muscles was performed. After the surgery, diplopia disappeared,the fundus photography showed no excyclotorsion, and the double Maddox rod test indicated 3° of excyclotorsion. Conclusions: Cisternography should be carefully performed due to the possibility of bilateral trochlear nerve palsy, an extremelyrare but possible occurrence following the procedure.
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