The use of diffusion magnetic resonance imaging tractography in supporting anatomical conflict between an uncal protrusion and the oculomotor nerve: A case report of isolated inferior rectus palsy

BACKGROUND: Isolated inferior rectus muscle palsy is a rare entity and even more rarely induced by an anatomical conflict. We report here a clinical case of third cranial nerve (CN III) compression in its cisternal segment by an idiopathic uncal protrusion in a patient presenting an isolated inferior rectus muscle palsy. CASE DESCRIPTION: We report a case of an anatomical conflict between the uncus and the CN III in the form of a protrusion and highly asymmetrical proximity of the uncus and asymmetrically thinned nerve diameter deviated from its straight cisternal trajectory on the ipsilateral side were supported by an altered diffusion tractography along the concerned CN III. Clinical description, review of the literature, and image analysis were done including CN III fiber reconstruction using a fused image from diffusion tensor imaging images, constructive interference in steady state, and T2-fluid-attenuated inversion recovery images on a dedicated software (BrainLAB AG). CONCLUSION: This case illustrates the importance of anatomical-clinical correlation in cases of CN deficits and supports the use of new neuroradiologically based interrogation methods such as CN diffusion tractography to support anatomical CN conflicts.