Clinical Pathways in Neuro-ophthalmology : An ... - E-Lib FK UWKS

446 Clinical Pathways in Neuro-Ophthalmology, second edition
brainstem and lateral column of the spinal cord to exit at the cervical (C8) and thoracic
(T1-T2) levels (ciliospinal center of Budge) of the spinal cord as a second-order neuron.
This second-order (intermediate) preganglionic neuron exits the ventral root and arches
over the apex of the lung to ascend in the cervical sympathetic chain. The second-order
neurons synapse in the superior cervical ganglion and exit as a third-order neuron. The
neural fibers for sweating of the face travel with the external carotid artery. The thirdorder
postganglionic neuron travels with the carotid artery into the cavernous sinus.
Within the cavernous sinus, the sympathetic fibers join the abducens nerve for a short
course and then travel with the ophthalmic division of the trigeminal nerve and join the
nasociliary branch of the trigeminal nerve. The fibers pass through the ciliary ganglion
and to the eye as the long and short ciliary nerves (Burde, 1992; Miller, 1985).
The evaluation of HS includes two stages (Burde, 1992; Miller, 1985): (1) recognition of
the clinical syndrome, and (2) confirmation and localization by pharmacologic testing.
Is the HS Isolated?
Nonisolated HS should undergo imaging with attention to the topographic localization
of the clinical findings.
Is a Central HS Present?
Patients with a central HS can usually be identified by the presence of associated
hypothalamic or brainstem signs or symptoms (e.g., contralateral fourth nerve palsy,
diabetes insipidus, disturbed temperature or sleep regulation, meningeal signs, vertigo,
sensory deficits, anhidrosis of the body, etc.). The etiologies of central HS are listed in
Table 20–9.
Is a Preganglionic (Intermediate) HS Present?
The preganglionic (intermediate) HS patient may have neck or arm pain, anhidrosis
involving the face and neck, brachial plexopathy, vocal cord paralysis, or phrenic nerve
palsy (Burde, 1992). The etiologies of preganglionic intermediate HS are listed in
Table 20–10.
Is a Postganglionic HS Present?
The postganglionic HS patient may have ipsilateral pain and other symptoms suggestive
of cluster or migraine headaches (e.g., tearing, facial flushing, rhinorrhea)
(DeMarinis, 1994; Manzoni, 1991). Anhidrosis in postganglionic HS is often absent
(Thompson, 1977b). Sweat glands of the forehead are supplied by the terminal branches
of sympathetics to the internal carotid, and involvement of these fibers after they have
separated from the remaining facial sweat fibers may explain the occurrence of
anhidrosis of the forehead with sparing of the rest of the face in these patients.
Postganglionic HS due to cavernous sinus lesions (e.g., thrombosis, infection, neoplasm)