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Neuroimaging Strategies for Three Types of Horner Syndrome with Emphasis on Anatomic Location

¹ Department of Radiology and Research Insitute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-2dong, Songpa-gu, 138-736, Seoul, South Korea.
² Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

View larger version (29K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Drawing shows normal anatomy of oculosympathetic pathway. First-order neuron (dashed line) arises from posterolateral hypothalamus, descends into brainstem and intermediolateral column of spinal cord, and exits at cervical (C8) and thoracic (T1-T2) levels of spinal cord as second-order neuron (dotted line). Second-order preganglionic neurons exit ventral spinal roots (a) and arch over apex of lung to ascend in cervical sympathetic chain, synapsing in superior cervical ganglion (b) and exiting as third-order neuron (solid lines). Neural fibers for sweating of face, except medial forehead, travel with external carotid artery. Third-order postganglionic neuron travels with carotid artery (c) into cavernous sinus and with ophthalmic branch (d) of fifth cranial nerve joins nasociliary branch of fifth cranial nerve or passes through ciliary ganglion (e) directly, reaching eye as long (f) and short (g) ciliary nerves [7, 8]. Preganglionic parasympathetic fibers (gray lines) arise from accessory oculomotor nucleus (h), exit as oculomotor nerve (i), synapse at ciliary ganglion, and reach eye as short ciliary nerves.

View larger version (23K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —Pharmacologic diagnosis and localization of Horner syndrome. Instillation of one drop of 10% cocaine solution is used for pharmacologic diagnosis. Cocaine inhibits reuptake of norepinephrine at synaptic junction of postganglionic fibers and iris dilator muscle and results in pupillary dilation, but in Horner syndrome pupil does not dilate. One percent hydroxyamphetamine solution releases norepinephrine from sympathetic synaptic terminal, which dilates pupil in Horner syndrome only if postganglionic neuron is intact. So 1% hydroxyamphetamine solution can be used for differential diagnosis of central and preganglionic from postganglionic lesions.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —68-year-old woman with sudden neurologic symptoms and signs including disorientation, left miosis, ptosis, and anhidrosis. Axial T2-weighted image of brain shows acute infarction in anteromedial thalamus.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —68-year-old woman with sudden neurologic symptoms and signs including disorientation, left miosis, ptosis, and anhidrosis. Axial T2-weighted image of brain at lower level than A shows acute infarction involving left posteromedial hypothalamus and left cerebral peduncle of midbrain.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —46-year-old man with right hemiplegia of sudden onset after swimming. Left miosis, ptosis, and hypohidrosis were found at neurologic examination. Axial T2-weighted image of brainstem shows acute lateral medullary infarct (arrow) on left side.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —46-year-old man with right hemiplegia of sudden onset after swimming. Left miosis, ptosis, and hypohidrosis were found at neurologic examination. Axial T1-weighted image shows hyperintense thrombus along left distal vertebral artery (arrow).

View larger version (82K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —43-year-old woman with known papillary thyroid carcinoma. Total thyroidectomy with bilateral modified radical neck dissection was performed. In operative field, right sympathetic chain had thyroid adhesions and was difficult to dissect. Right ptosis developed on first postoperative day. Preoperative CT image of neck depicts heterogeneous masses in both lobes of thyroid and metastasis in both level IV lymph nodes (long arrows). Mass in right lobe shows exophytic growth and disruption of fat plane (short arrows) between mass and prevertebral muscle.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —22-year-old man with palpable neck mass. Coronal T2-weighted MR image of neck shows well-defined, ovoid hyperintense mass compressing medial aspect of prevertebral muscle.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —22-year-old man with palpable neck mass. Axial contrast-enhanced T1-weighted image depicts heterogeneously enhanced ovoid mass (arrow) between left carotid and prevertebral spaces. Surgical excision confirmed mass as schwannoma arising from left cervical sympathetic trunk. Two days after surgery, patient reported left ptosis and visual dimness, findings suggestive of left preganglionic Horner syndrome resulting from surgical trauma to cervical sympathetic trunk.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —64-year-old woman with paresthesia of left arm and left ptosis with hypohidrosis and no clinical history of recent trauma. Axial contrast-enhanced CT image at level of thoracic inlet depicts infiltrative enhancing mass (asterisk).

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —64-year-old woman with paresthesia of left arm and left ptosis with hypohidrosis and no clinical history of recent trauma. CT image shows mass partly encasing left subclavian artery (arrow) at level of apex of left lung. Mass was confirmed to be squamous cell carcinoma of lung causing clinical symptoms of Pancoast syndrome.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —41-year-old man who reported left anhidrosis and ptosis. Patient also had left miosis but no associated symptom or sign except left Horner syndrome of central or preganglionic type. Contrast-enhanced CT image of thoracic inlet shows relatively well-defined homogeneous mass (arrow) without encapsulation in left side of superior mediastinum. Mass was attached to anterolateral aspect of T1 and T2 vertebral bodies. Surgical excision confirmed mass as fibromatosis closely attached to sympathetic trunk.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —53-year-old woman with right shoulder and hand pain, right miosis, ptosis, and hypohidrosis of entire right side of face. Clinical findings suggest tumor possibly involving brachial plexus with preganglionic Horner syndrome. Sagittal T2-weighted MR image of brachial plexus shows hypointense mass (asterisk) between anterior (ASM) and middle (MSM) scalene muscles.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —53-year-old woman with right shoulder and hand pain, right miosis, ptosis, and hypohidrosis of entire right side of face. Clinical findings suggest tumor possibly involving brachial plexus with preganglionic Horner syndrome. Sagittal T1-weighted image shows isointense mass (asterisk) not clearly separated from adjacent muscles.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —53-year-old woman with right shoulder and hand pain, right miosis, ptosis, and hypohidrosis of entire right side of face. Clinical findings suggest tumor possibly involving brachial plexus with preganglionic Horner syndrome. Coronal contrast-enhanced T1-weighted MR image depicts homogeneous enhancement of mass (asterisk) infiltrating roots of brachial plexus. Surgical finding was neurofibroma.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —48-year-old man with left occipital headache and left ptosis, left miosis, hypohidrosis of left medial part of forehead, paresthesia of area innervated by ophthalmic branch of left fifth cranial nerve, and decreasing visual acuity. Neck CT angiography was performed to rule out carotid artery dissection. Curved planar reformatted CT image shows dissection of cervical carotid artery and hypoattenuating thrombus in false lumen (arrows).

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —48-year-old man with left occipital headache and left ptosis, left miosis, hypohidrosis of left medial part of forehead, paresthesia of area innervated by ophthalmic branch of left fifth cranial nerve, and decreasing visual acuity. Neck CT angiography was performed to rule out carotid artery dissection. Maximum-intensity-projection image of contrast-enhanced MR angiogram on same day as A shows only mild luminal irregularity of distal cervical internal carotid artery (arrow).

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —48-year-old man with left occipital headache and left ptosis, left miosis, hypohidrosis of left medial part of forehead, paresthesia of area innervated by ophthalmic branch of left fifth cranial nerve, and decreasing visual acuity. Neck CT angiography was performed to rule out carotid artery dissection. Axial source image of neck CT angiogram shows low-attenuating thrombus (arrow) in false lumen.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10D —48-year-old man with left occipital headache and left ptosis, left miosis, hypohidrosis of left medial part of forehead, paresthesia of area innervated by ophthalmic branch of left fifth cranial nerve, and decreasing visual acuity. Neck CT angiography was performed to rule out carotid artery dissection. Axial T2-weighted MR image shows hyperintense thrombus (arrow) in false lumen.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —67-year-old woman with right ptosis, diplopia, and miosis. (Reprinted from [9]) Axial T2-weighted image shows large signal void (arrows) due to aneurysms of internal carotid arteries in both cavernous sinuses.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —67-year-old woman with right ptosis, diplopia, and miosis. (Reprinted from [9]) Coronal contrast-enhanced T1-weighted image shows crescent isointense thrombus (arrows) in right aneurysm and intense enhancement of left aneurysm.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —67-year-old woman with right ptosis, diplopia, and miosis. (Reprinted from [9]) Digital subtraction angiogram of both internal carotid arteries shows partially thrombosed aneurysms of internal carotid artery of right cavernous sinus (long arrow) and another aneurysm of internal carotid artery of left cavernous sinus (short arrows).

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —50-year-old man with right facial pain. Neurologic examination revealed right miosis, ptosis, and palsy of sixth and maxillary branch of fifth cranial nerves. Coronal T2-weighted image shows homogeneous infiltrating lesion (arrow) in right anterior cavernous sinus.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —50-year-old man with right facial pain. Neurologic examination revealed right miosis, ptosis, and palsy of sixth and maxillary branch of fifth cranial nerves. Contrast-enhanced axial T1-weighted image shows homogeneous intense enhancement (arrow) of infiltrating lesion. Tolosa-Hunt syndrome was confirmed.

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