Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis  Miosis  Anhidrosis Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis  Miosis  Anhidrosis Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What Miosis does the term ‘ptosis’ mean in this context? It describes an abnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis In Horner syndrome, does this ‘abnormal narrowing’ involve the upper lid, the lower lid, or both? Both

With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What Miosis does the term ‘ptosis’ mean in this context? It describes an abnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis In Horner syndrome, does this ‘abnormal narrowing’ involve the upper lid, the lower lid, or both? Both

With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What Miosis does the term ‘ptosis’ mean in this context? It describes an abnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis In Horner syndrome, does this ‘abnormal narrowing’ involve the upper lid, the lower lid, or both? Both

With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What Miosis does the term ‘ptosis’ mean in this context? It describes an abnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis In Horner syndrome, does this ‘abnormal narrowing’ involve the upper lid, the lower lid, or both? Both

With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What Miosis does the term ‘ptosis’ mean in this context? It describes an abnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis In Horner syndrome, does this ‘abnormal narrowing’ involve the upper lid, the lower lid, or both? Both

With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too… The lower lid is too… Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What Miosis does the term ‘ptosis’ mean in this context? It describes an abnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis In Horner syndrome, does this ‘abnormal narrowing’ involve the upper lid, the lower lid, or both? Both

With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What Miosis does the term ‘ptosis’ mean in this context? It describes an abnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis In Horner syndrome, does this ‘abnormal narrowing’ involve the upper lid, the lower lid, or both? Both

With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low Note: Some authors refer to this malpositioning of the LL The lower lid is too…high as ‘reverse ptosis;’ however, to the best of my ability to ascertain, this term doers not appear in any BCSC book Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both Is levator dysfunction implicated in the ptosis associated with Horners? No With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both Is levator dysfunction implicated in the ptosis associated with Horners? No With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both Is levator dysfunction implicated in the ptosis associated with Horners? No With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both Is levator dysfunction implicated in the ptosis associated with Horners? No With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both Is levator dysfunction implicated in the ptosis associated with Horners? No With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both Is levator dysfunction implicated in the ptosis associated with Horners? No With regard to each lid, how is it (mal)positioned in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? It forms a narrow strip between the distal tendon of the levator and the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? It forms a narrow strip between the distal tendon of the levator and the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? It forms a narrow strip between the distal tendon of the levator and the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ me anof positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? It forms a narrow strip between the distal tendon of the levator and the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Smooth muscle fibers…What does thisWhere imply is Müller’sabout the muscle innervation located? of Müller’s muscle? It implies its innervation is via the ANSIt forms (in this a narrowcase, the strip sy mpatheticbetween the branch distal of tendon the ANS) of the levator and the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Smooth muscle fibers…What does thisWhere imply is Müller’sabout the muscle innervation located? of Müller’s muscle? It implies its innervation is via the ANSIt forms (in this a narrowcase, the strip sy mpatheticbetween the branch distal of tendon the ANS) of the levator and the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? It forms a narrow strip between the distal tendon of the levator and the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid 24 Horner Syndrome

Müller’s muscle Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an abnormal superioris and unintended narrowing of the interpalpebral fissure If innervation Anhidrosis to the levator is lost, how much ptosis results? Total/complete—theWhat nerveIn Horner innervates syndrome, lid is theclosed levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? If innervationBoth to Müller’s muscle is lost, howIf notmuch the ptosis levator, results? what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? Not nearly so much—about 2 mm or so the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an abnormal superioris and unintended narrowing of the interpalpebral fissure If innervation Anhidrosis to the levator is lost, how much ptosis results? Total/complete—theWhat nerveIn Horner innervates syndrome, lid is theclosed levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? If innervationBoth to Müller’s muscle is lost, howIf notmuch the ptosis levator, results? what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? Not nearly so much—about 2 mm or so the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an abnormal superioris and unintended narrowing of the interpalpebral fissure If innervation Anhidrosis to the levator is lost, how much ptosis results? Total/complete—theWhat nerveIn Horner innervates syndrome, lid is theclosed levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? If innervationBoth to Müller’s muscle is lost, howIf notmuch the ptosis levator, results? what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? Not nearly so much—about 2 mm or so the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an abnormal superioris and unintended narrowing of the interpalpebral fissure If innervation Anhidrosis to the levator is lost, how much ptosis results? Total/complete—theWhat nerveIn Horner innervates syndrome, lid is theclosed levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? If innervationBoth to Müller’s muscle is lost, howIf notmuch the ptosis levator, results? what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? Not nearly so much—about 2# mm or so the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an abnormal superioris and unintended narrowing of the interpalpebral fissure If innervation Anhidrosis to the levator is lost, how much ptosis results? Total/complete—theWhat nerveIn Horner innervates syndrome, lid is theclosed levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? If innervationBoth to Müller’s muscle is lost, howIf notmuch the ptosis levator, results? what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? Not nearly so much—about 2 mm or so the ptosis associated with Horners? No With regard to each lid, how isMüller’s it (mal)positioned muscle in ptosis 2ndry to Horners? The upper lid is too…low The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smooth

Where is Müller’s muscle located? Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid 30 Horner Syndrome

Horner’s ptosis in adult

Horner’s ptosis in infant

Horner syndrome: Ptosis 31 Horner Syndrome

Horner’s ptosis in adult

Not Horner’s ptosis in child (ptoo ptotic)

Horner’s ptosis in infant Not Horner’s ptosis in adult (ptoo ptotic)

Horner syndrome: Ptosis Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it If(mal Müller’s)positioned muscle muscle is in in ptosis the upper 2ndry lid, towhat Horners? accounts for the Horner-related ptosis of the lower lid? The upper lid is too…low The lower lid contains a set of smooth-muscle fibers that function The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smoothin a manner analogous to Müller’s muscle, and are innervated in identical fashion. (These LL fibers are less-organized and far Whereweaker is Müller’s than those muscle comprising located? Müller’s muscle.) Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it If(mal Müller’s)positioned muscle muscle is in in ptosis the upper 2ndry lid, towhat Horners? accounts for the Horner-related ptosis of the lower lid? The upper lid is too…low The lower lid contains a set of smooth-muscle fibers that function The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smoothin a manner analogous to Müller’s muscle, and are innervated in identical fashion. (These LL fibers are less-organized and far Whereweaker is Müller’s than those muscle comprising located? Müller’s muscle.) Deep to the distal tendon of the levator; it attaches to the superior border of the tarsal plate of the upper lid Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it If(mal Müller’s)positioned muscle muscle is in in ptosis the upper 2ndry lid, towhat Horners? accounts for the Horner-related ptosis of the lower lid? The upper lid is too…low The lower lid contains a set of smooth-muscle fibers that function The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smoothin a manner analogous to Müller’s muscle, and are innervated in identical fashion. (These LL fibers are less-organized and far Whereweaker is Müller’sDoes than thosethis muscle collection comprising located? of LL Müller’s smooth muscle.) muscle fibers have Deep to thea name?distal tendon of the levator; it attaches to the superiorNot border really of(although the tarsal it isplate sometimes of the upper referred lid to as the capsulopalpebral muscle because of its location) Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it If(mal Müller’s)positioned muscle muscle is in in ptosis the upper 2ndry lid, towhat Horners? accounts for the Horner-related ptosis of the lower lid? The upper lid is too…low The lower lid contains a set of smooth-muscle fibers that function The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smoothin a manner analogous to Müller’s muscle, and are innervated in identical fashion. (These LL fibers are less-organized and far Whereweaker is Müller’sDoes than thosethis muscle collection comprising located? of LL Müller’s smooth muscle.) muscle fibers have Deep to thea name?distal tendon of the levator; it attaches to the superiorNot border really of(although the tarsal it isplate sometimes of the upper referred lid to as the capsulopalpebral muscle because of its location) Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis What muscleWhat Miosis doesis most the influential term ‘ptosis in terms’ mean of positioningin this context? the upper lid? The levatorIt describes palpebrae an superiorisabnormal and unintended narrowing of the interpalpebral fissure  Anhidrosis What nerveIn Horner innervates syndrome, the levator? does this ‘abnormal narrowing’ involve the upper lid, the CN3 lower lid, or both? Both If not the levator, what named muscle is implicated in Is levator dysfunction implicated in the ptosis associated with Horners? the ptosis associated with Horners? No With regard to each lid, how isMüller’s it If(mal Müller’s)positioned muscle muscle is in in ptosis the upper 2ndry lid, towhat Horners? accounts for the Horner-related ptosis of the lower lid? The upper lid is too…low The lower lid contains a set of smooth-muscle fibers that function The lower lid is too…high Are the fibers in Müller’s muscle striated, or smooth? Smoothin a manner analogous to Müller’s muscle, and are innervated in identical fashion. (These LL fibers are less-organized and far Whereweaker is Müller’sDoes than thosethis muscle collection comprising located? of LL Müller’s smooth muscle.) muscle fibers have Deep to thea name?distal tendon of the levator; it attaches to the superiorNot border really of(although the tarsal it isplate sometimes of the upper referred lid to as the capsulopalpebral muscle because of its location) Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis  Miosis How does Anhidrosis sympathetic dysfunction result in a relatively miotic pupil? At any given moment, the size of a pupil is determined by the sum total of sympathetic and parasympathetic innervation being received by its dilator and sphincter muscles, respectively. Thus, if the amount of sympathetic (=pro-dilating) innervation is reduced in one eye, its relatively unopposed parasympathetic (=pro-miosing) inputs will have an outsized effect, and its pupil will be relatively miosed in comparison to that of the fellow eye. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis  Miosis How does Anhidrosis sympathetic dysfunction result in a relatively miotic pupil? At any given moment, the size of a pupil is determined by the sum total of sympathetic and parasympathetic innervation being received by its dilator and sphincter muscles, respectively. Thus, if the amount of sympathetic (=pro-dilating) innervation is reduced in one eye, its relatively unopposed parasympathetic (=pro-miosing) inputs will have an outsized effect, and its pupil will be relatively miosed in comparison to that of the fellow eye. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis  Miosis How does Anhidrosis sympathetic dysfunction result in a relatively miotic pupil? At any given moment, the size of a pupil is determined by the sum total of sympathetic and parasympathetic innervation being received by its dilator and sphincter muscles, respectively. Thus, if the amount of sympathetic (=pro-dilating) innervation is reduced in one eye, its relatively unopposed parasympathetic (=pro-miosing) inputs will have an outsized effect, and its pupil will be relatively miosed in comparison to that of the fellow eye. 40 Horner Syndrome

Horner’s miosis in adult

Horner’s miosis in infant

Horner syndrome: Miosis Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria How does Anhidrosis sympathetic dysfunction result in a relatively miotic pupil? At any given moment, the size of a pupil is determined by the sum total of sympathetic and parasympathetic innervation being received by its dilator and sphincter muscles, respectively. Thus, if the amount of sympathetic (=pro-dilating) innervation is reduced in one eye, its relatively unopposed parasympathetic (=pro-miosing) inputs will have an outsized effect, and its pupil will be relatively miosed in comparison to that of the fellow eye. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria How does Anhidrosis sympathetic dysfunction result in a relatively miotic pupil? At any given moment, the size of a pupil is determined by the sum total of sympathetic and parasympathetic innervation being received by its dilator and sphincter muscles, respectively. Thus, if the amount of sympathetic (=pro-dilating) innervation is reduced in one eye, its relatively unopposed parasympathetic (=pro-miosing) inputs will have an outsized effect, and its pupil will be relatively miosed in comparison to that of the fellow eye. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the smaller pupil failing to dilate properly? total of sympathetic and parasympathetic innervation being received by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the smaller pupil failing to dilate properly? total of sympathetic and parasympathetic innervation being received by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the smaller pupil failing to dilate properly? total of sympathetic and parasympathetic innervation being received by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the smaller pupil failing to dilate properly? total of sympathetic and parasympathetic innervation being received by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympatheticANS division problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the smaller pupil failing to dilate properly? total of sympathetic and parasympathetic innervation being received by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. 48 Horner Syndrome

Horner syndrome: Anisocoria greater in dim light Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the smaller pupil failing to dilate properly? total of sympathetic and parasympathetic innervation being received by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympatheticANS division problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the smaller pupil failing to dilate properly? total of sympathetic and parasympathetic innervation being received by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the Whatsmaller if the pupilanisocoria failing to is dilate the same properly? under all lighting conditions? Thentotal of it sympatheticis nonpathologic and orparasympathetic physiological innervationanisocoria being(a common received finding) by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the Whatsmaller if the pupilanisocoria failing to is dilate the same properly? under all lighting conditions? Thentotal of it sympatheticis nonpathologic and orparasympathetic physiological innervationanisocoria being(a common received finding) by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

 Cause: Sympathetic dysfunction  Triad:  Ptosis ‘Relatively miotic’ implies the pupils are not the same size. What term describes a state of unequal pupil sizes?  Miosis Anisocoria HowWhen does Anhidrosis faced sympathetic with anisocoria, dysfunction what do result you want in a torelatively know first mioticand foremost? pupil? At anyWhich given pupil moment, (if either) the is ‘the size culprit’; of a pupilie, is theis determined larger pupil failing by the to sconstrictum properly, or is the Whatsmaller if the pupilanisocoria failing to is dilate the same properly? under all lighting conditions? Thentotal of it sympatheticis nonpathologic and orparasympathetic physiological innervationanisocoria being(a common received finding) by itsHow dilator can youand tell sphincter which pupil mu isscles, the culprit? respectively. Thus, if the amount of sympatheticBy determining (=pro-dilating) the lighting condition innervation under iswhich reduced the anisocori in one aey ise, more its pronounced. If the relativelyanisocoria unopposed is more pronouncedparasympathetic in dim light, (=pro-miosing) this indicates inputs the smaller will havepupil isn’t dilating properly, an outsizedand thus effect,is abnormal. and itsA pupil pupil that will fails be to relatively dilate is suggestiv miosede in of c aomparison sympathetic problem. to thatLikewise, of the iffellow the anisocoria eye. is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic problem. Horner Syndrome

Neural pathway in Horner syndrome: First-orderFirst of three neuroncomponents --Originates in hypothalamus --Travels in spinal cord --Synapses in ciliospinal center of Budge

Second-orderSecond of three components neuron --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-orderThird of three componentsneuron --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originates in hypothalamus --Travels in spinal cord --Synapses in ciliospinal center of Budge

Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamusstructure --Travels in spinal cord --Synapses in ciliospinal center of Budge

Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travels in spinal cord --Synapses in ciliospinal center of Budge

Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinaltwo cordwords --Synapses in ciliospinal center of Budge

Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapses in ciliospinal center of Budge

Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal centerfour words of Budge

Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord At what level of the spinal cord is the --Synapse in ciliospinal center of Budge center of Budge found? C8-T2 Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord At what level of the spinal cord is the --Synapse in ciliospinal center of Budge center of Budge found? C8-T2 Second-order neurons --Originates at Budge center --Exits spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit 64 Horner Syndrome

Müller’s muscle Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinaltwo cord words --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord --Travels in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetictwo words chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord What major structure do these fibers pass over? --Travel in sympathetic chain The lung apex --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord What major structure do these fibers pass over? --Travel in sympathetic chain The lung apex --Synapses in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord What major structure do these fibers pass over? --Travel in sympathetic chain The lung apex --Synapses in superior cervical ganglion Foreshadowing alert! Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervicalthree words ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglion

Third-order neurons --Originates in superior cervical ganglion --Travels with internal carotid artery into cavernous sinus --Hops onto VI, then V1 to enter orbit 74 Horner Syndrome

Sympathetic pathway: 2nd order neuron Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…?

Third-order neurons By what other name is the superior cervical ganglion known? --Originates in superior cervicalThe stellate ganglion ganglion --Travels with internal carotidSpeaking artery of other into names…The second-order neurons are often cavernous sinus referred to by another name, one owing to the relationship between --Hops onto VI, then V1 tothese enter neurons orbit and the ganglion to which they are headed. What is that name? Pre-ganglionic neurons Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons By what other name is the superior cervical ganglion known? --Originates in superior cervicalThe stellate ganglion ganglion --Travels with internal carotidSpeaking artery of other into names…The second-order neurons are often cavernous sinus referred to by another name, one owing to the relationship between --Hops onto VI, then V1 tothese enter neurons orbit and the ganglion to which they are headed. What is that name? Pre-ganglionic neurons Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…? --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons By what other name is the superior cervical ganglion known? --Originates in superior cervicalThe stellate ganglion ganglion --Travels with internal carotidSpeaking artery of other into names…The second-order neurons are often cavernous sinus referred to by another name, one owing to the relationship between --Hops onto VI, then V1 tothese enter neurons orbit and the ganglion to which they are headed. What is that name? Pre-ganglionic neurons Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons By what other name is the superior cervical ganglion known? --Originates in superior cervicalThe stellate ganglion ganglion --Travels with internal carotidSpeaking artery of other into names…The second-order neurons are often cavernous sinus referred to by another name, one owing to the relationship between --Hops onto VI, then V1 tothese enter neurons orbit and the ganglion to which they are headed. What is that name? Pre-ganglionic neurons Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons --Originate in superior cervical ganglion --Hops onto VI, then V1 to enter orbit

(No question—proceed when ready) 80 Horner Syndrome

Sympathetic pathway: 3rd order neuron Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…? --Originate in superior cervical ganglion --Hops onto VI, then V1 to enter orbit Likewise, the third-order neurons are also referred to by a term owing to their relationship with the stellate ganglion. What is that term? Post-ganglionic neurons Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Hops onto VI, then V1 to enter orbit Likewise, the third-order neurons are also referred to by a term owing to their relationship with the stellate ganglion. What is that term? Post-ganglionic neurons Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internalthree carotid words artery to enter the cavernoustwo words sinus --Hops onto VI, then V1 to enter orbit Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --Hops onto VI, then V1 to enter orbit 85 Horner Syndrome

Internal carotid a.

Sympathetic pathway: 3rd order neuron Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --In the sinus: cranial different cranial ----Fibers bound for the pupil join CN6nerve , then V1 nerve Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 88 Horner Syndrome

Sympathetic pathway: 3rd order neuron Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain For--Synapse how long do in these superior pupil-bound cervical postgangli gangliononicaka…the sympathetic stellate fibers runganglion with CN6? Not long--just a few millimeters Third-order neurons aka…post-ganglionic neurons If it’s--Originate so trivial, whyin superior bother mentioning cervical ganglion the relationship at all? Because of its importance in lesion localization. If a pt presents with a LR palsy + ipsilateral--Travel miotic with pupil,internal the carotidlesion must arterybe tolocated enter in the the cavernous cavernous sinus!sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain For--Synapse how long do in these superior pupil-bound cervical postgangli gangliononicaka…the sympathetic stellate fibers runganglion with CN6? Not long--just a few millimeters Third-order neurons aka…post-ganglionic neurons If it’s--Originate so trivial, whyin superior bother mentioning cervical ganglion the relationship at all? Because of its importance in lesion localization. If a pt presents with a LR palsy + ipsilateral--Travel miotic with pupil,internal the carotidlesion must arterybe tolocated enter in the the cavernous cavernous sinus!sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain For--Synapse how long do in these superior pupil-bound cervical postgangli gangliononicaka…the sympathetic stellate fibers runganglion with CN6? Not long--just a few millimeters Third-order neurons aka…post-ganglionic neurons If it’s--Originate so trivial, whyin superior bother mentioning cervical ganglion the relationship at all? Because of its importance in lesion localization. If a pt presents with a LR palsy + ipsilateral--Travel miotic with pupil,internal the carotidlesion must arterybe tolocated enter in the the cavernous cavernous sinus!sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain For--Synapse how long do in these superior pupil-bound cervical postgangli gangliononicaka…the sympathetic stellate fibers runganglion with CN6? Not long--just a few millimeters Third-order neurons aka…post-ganglionic neurons If it’s--Originate so trivial, whyin superior bother mentioning cervical ganglion the relationship at all? Because of its importance in lesion localization. If a pt presents with a LR palsy + ipsilateral--Travel miotic with pupil,internal the carotidlesion must arterybe tolocated enter in the the cavernous cavernous sinus!sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinal cord -- --Synapse in ciliospinal center of Budge --

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinal cord -- --Synapse in ciliospinal center of Budge --

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinal cord -- --Synapse in ciliospinal center of Budge --

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinal cord -- Mnemonic forthcoming… --Synapse in ciliospinal center of Budge --

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalN cord --F Mnemonic forthcoming… --Synapse in ciliospinal center of Budge --L

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal Mnemonic forthcoming… --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 99 Horner Syndrome

V1 V V 2

V3

Ophthalmic nerve (V1) Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Will the sympatheticsUpon leaving synapseaka…post-ganglionic the in the ganglion, ciliary ganglion with whic as well?h nerves neurons do the sympathetics ride on No.--Originate Remember, inthese superior are post cervicalganglionic ganglion sympathetics. They will passtheir through way the to ganglion the dilator without muscle? synapsing. --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Will the sympatheticsUpon leaving synapseaka…post-ganglionic the in the ganglion, ciliary ganglion with whic as well?h nerves neurons do the sympathetics ride on No.--Originate Remember, inthese superior are post cervicalganglionic ganglion sympathetics. They will passtheir through way the to ganglion the dilator without muscle? synapsing. --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --OriginateV1 in (aka hypothalamus the ophthalmic nerve) breaks into three branches. What are they? --Travel in-- spinalNasociliary cord --Frontal --Synapse in ciliospinal center of Budge --Lacrimal

Second-orderWith neuronswhich branchaka…pre-ganglionic do the postganglionic sympathetics neurons run? --OriginateThe at Budgenasociliary center --Exit spinal cord --Travel inThe sympathetic nasociliary chain nerve also carries preganglionic parasympathetics in need of --Synapsea inganglion superior in whichcervical to synapse. ganglion To which ganglion are these fibers headed? The ciliary ganglion aka…the stellate ganglion Third-order neurons Upon leavingaka…post-ganglionic the ganglion, with which nerves neurons do the sympathetics ride on --Originatetheir in superior way to the cervical dilator muscle? ganglion --Travel withThe internal long ciliary carotid nerves artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 108 Horner Syndrome

Sympathetic pathway: 3rd order neuron Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 ----Fibers bound for Mueller’s muscle, as well as…

(No question—proceed when ready) Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 ----Fibers bound for Mueller’s muscle, as well as… ----Fibers bound for sweat glands of the forehead hop onto the ophthalmic artery, and then onto its frontal and lacrimal branches Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --In the sinus: ----Fibers bound for the pupil join CN6 , then V1 ----Fibers bound for Mueller’s muscle, as well as… ----Fibers bound for sweat glands of the forehead hop onto the ophthalmic artery, and then onto its frontal and lacrimal branches Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --OriginateWhat about in sweat superior glands cervical of the ganglionlower face--how do sympathetics get to them? --TravelPostganglionic with internal fibers carotiddestined artery to innervate to enter lower-face the cavernous sweat gl andssinus don’t run with --Inthe the internal sinus: carotid; rather, at the carotid bulb they hop onto the external carotid, ----Fibersthen onto bound its branches for the to pupil reach join their CN6 destinations , then V1 on the non-forehead face ----Fibers bound for Mueller’s muscle, as well as… ----Fibers bound for sweat glands of therest forehead of the face hop onto the ophthalmic ^ artery, and then onto its frontal and lacrimal branches Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --OriginateWhat about in sweat superior glands cervical of the ganglionlower face--how do sympathetics get to them? --TravelPostganglionic with internal fibers carotiddestined artery to innervate to enter lower-face the cavernous sweat gl andssinus don’t run with --Inthe the internal sinus: carotid; rather, at the carotid bulb they hop onto the external carotid, ----Fibersthen onto bound its branches for the to pupil reach join their CN6 destinations , then V1 on the non-forehead face ----Fibers bound for Mueller’s muscle, as well as… ----Fibers bound for sweat glands of therest forehead of the face hop onto the ophthalmic ^ artery, and then onto its frontal and lacrimal branches Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----Fiberscavernous sinusbound as for well? the pupil join CN6 , then V1 ----FibersNo--these hopbound off the for internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery, and then onto its frontal and lacrimal branches --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----Fiberscavernous sinusbound as for well? the pupil join CN6 , then V1 ----FibersNo--these hopbound off the for internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery, and then onto its frontal and lacrimal branches --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----Fiberscavernous sinusbound as for well? the pupil join CN6 , then V1 ----FibersNo--these hopbound off the for internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers of onthe their forehead way to hop innervate onto the the ophthalmic gland artery, and then ontoThese its preganglionic frontal and parasympathetic lacrimal branches fibers ‘belong’ to which cranial nerve? CN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----Fiberscavernous sinusbound as for well? the pupil join CN6 , then V1 ----FibersNo--these hopbound off the for internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers of onthe their forehead way to hop innervate onto the the ophthalmic gland artery, and then ontoThese its preganglionic frontal and parasympathetic lacrimal branches fibers ‘belong’ to which cranial nerve? CN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----Fiberscavernous sinusbound as for well? the pupil join CN6 , then V1 ----FibersNo--these hopbound off the for internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers of onthe their forehead way to hop innervate onto the the ophthalmic gland artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----Fiberscavernous sinusbound as for well? the pupil join CN6 , then V1 ----FibersNo--these hopbound off the for internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers of onthe their forehead way to hop innervate onto the the ophthalmic gland artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----FiberscavernousThese postganglionic sinusbound as for well?sympathetic the pupil fibers join f orm CN6 a named , then nerve V1 of their own--what is its name? ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus --InWhat the about sinus: fibers bound for the lacrimal gland--do they pass through the ----FiberscavernousThese postganglionic sinusbound as for well?sympathetic the pupil fibers join f orm CN6 a named , then nerve V1 of their own--what is its name? ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus What about fibers bound for theOnce lacrimal the deep gland--do petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? ----FiberscavernousThese postganglionic sinusbound as for well?sympathetic the pupilThe fibers join vidian form CN6 nervea named , then nerve V1 of their own--what is its name? ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotid artery to enter the cavernous sinus What about fibers bound for theOnce lacrimal the deep gland--do petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? ----FiberscavernousThese postganglionic sinusbound as for well?sympathetic the pupilThe fibers join vidian form CN6 nervea named , then nerve V1 of their own--what is its name? ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve siexitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka… nerve V1 of their own--what is its name? ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge center --Exit spinal cord --Travel in sympathetic chain --Synapse in superior cervical ganglionaka…the stellate ganglion

Third-order neurons aka…post-ganglionic neurons --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve siexitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge centerWhere is the vidian nerve headed when it leaves the skull? --Exit spinal cord The pterygopalatine ganglion --Travel in sympathetic chain Will the sympathetic fibers synapse in the pterygopalatine ganglion? --Synapse in superior cervicalNo, theyganglion are postganglionic,aka…the and stellate will pass throughganglion the ganglion without synapsing. Only the preganglionic parasympathetics will Third-order neurons aka…post-ganglionicsynapse in the pterygopalatine neurons ganglion. --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve si exitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge centerWhere is the vidian nerve headed when it leaves the skull? --Exit spinal cord The pterygopalatine ganglion --Travel in sympathetic chain Will the sympathetic fibers synapse in the pterygopalatine ganglion? --Synapse in superior cervicalNo, theyganglion are postganglionic,aka…the and stellate will pass throughganglion the ganglion without synapsing. Only the preganglionic parasympathetics will Third-order neurons aka…post-ganglionicsynapse in the pterygopalatine neurons ganglion. --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve si exitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge centerWhere is the vidian nerve headed when it leaves the skull? --Exit spinal cord The pterygopalatine ganglion --Travel in sympathetic chain Will the sympathetic fibers synapse in the pterygopalatine ganglion? --Synapse in superior cervicalNo, theyganglion are postganglionic,aka…the and stellate will pass throughganglion the ganglion without synapsing. Only the preganglionic parasympathetics will Third-order neurons aka…post-ganglionicsynapse in the pterygopalatine neurons ganglion. --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve si exitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --Synapse in ciliospinal center of Budge

Second-order neurons aka…pre-ganglionic neurons --Originate at Budge centerWhere is the vidian nerve headed when it leaves the skull? --Exit spinal cord The pterygopalatine ganglion --Travel in sympathetic chain Will the sympathetic fibers synapse in the pterygopalatine ganglion? --Synapse in superior cervicalNo, theyganglion are postganglionic,aka…the and stellate will pass throughganglion the ganglion without synapsing. Only the preganglionic parasympathetics will Third-order neurons aka…post-ganglionicsynapse in the pterygopalatine neurons ganglion. --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve si exitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --SynapseFinally: How in will ciliospinal the postganglionic center sympathetic of Budges and (now) postganglionic parasympathetics get to the lacrimal gland? They will pass through the inferior orbital fissure to join the lacrimal nerve on its way to the gland Second-order neurons aka…pre-ganglionic neurons --Originate at Budge centerWhere is the vidian nerve headed when it leaves the skull? --Exit spinal cord The pterygopalatine ganglion --Travel in sympathetic chain Will the sympathetic fibers synapse in the pterygopalatine ganglion? --Synapse in superior cervicalNo, theyganglion are postganglionic,aka…the and stellate will pass throughganglion the ganglion without synapsing. Only the preganglionic parasympathetics will Third-order neurons aka…post-ganglionicsynapse in the pterygopalatine neurons ganglion. --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve si exitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --SynapseFinally: How in will ciliospinal the postganglionic center sympathetic of Budges and (now) postganglionic parasympathetics get to the lacrimal gland? They will pass through the inferior orbital fissure to join the lacrimal nerve on its way to the gland Second-order neurons aka…pre-ganglionic neurons --Originate at Budge centerWhere is the vidian nerve headed when it leaves the skull? --Exit spinal cord The pterygopalatine ganglion --Travel in sympathetic chain Will the sympathetic fibers synapse in the pterygopalatine ganglion? --Synapse in superior cervicalNo, theyganglion are postganglionic,aka…the and stellate will pass throughganglion the ganglion without synapsing. Only the preganglionic parasympathetics will Third-order neurons aka…post-ganglionicsynapse in the pterygopalatine neurons ganglion. --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve si exitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? Horner Syndrome

Neural pathway in Horner syndrome: First-order neurons --Originate in hypothalamus --Travel in spinal cord --SynapseFinally: How in will ciliospinal the postganglionic center sympathetic of Budges and (now) postganglionic parasympathetics get to the lacrimal gland? They will pass through the inferior orbital fissure to join the lacrimal nerve on its way to the gland Second-order neurons aka…pre-ganglionic neurons --Originate at Budge centerWhere is the vidian nerve headed when it leaves the skull? --Exit spinal cord The pterygopalatine ganglion --Travel in sympathetic chain Will the sympathetic fibers synapse in the pterygopalatine ganglion? --Synapse in superior cervicalNo, theyganglion are postganglionic,aka…the and stellate will pass throughganglion the ganglion without synapsing. Only the preganglionic parasympathetics will Third-order neurons aka…post-ganglionicsynapse in the pterygopalatine neurons ganglion. --Originate in superior cervical ganglion --Travel with internal carotidBy artery what passage to enter does the the cavernous vidian nerve si exitnus the skull? What about fibers bound for theOnceThe lacrimal vidian the deep gland--do canal petrosal theyand greater pass through petrosal nervesthe join up, --In the sinus: they form a new named nerve--what is its name? cavernous sinus as well? ----FibersThese postganglionic bound for sympathetic the pupilThe fibers join vidian form CN6 nervea named , thenaka…the nerve V1 of nerve their own--what of the vidian is its name? canal ----FibersNo--theseThe deep petrosal hopbound off the nervefor internal Mueller’s carotid muscle before it enters the sinus, and join the preganglionic----Fibers bound parasympathetic for sweat glands fibers on of theirthe foreheadway to innervate hop onto the glandthe ophthalmic artery,These preganglionic and then ontoparasympatheticThese its preganglionic frontal fibers and parasympatheticform lacrimal a named nerve--what branches fibers ‘belong’ is its to name? which cranial nerve? The greater petrosal nerveCN7 --Fibers bound for the lacrimal gland? 133 Horner Syndrome

Sympathetic pathway overview 134 Horner Syndrome

Sympathetic pathway overview 135 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: 136 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central 137 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 138 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 139

Wallenberg (aka lateral medullary) syndrome 140 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 141 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 142 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 143 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 144 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? -- --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 145 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 146 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion Wallenberg’s hallmark symptom is sensory--what is it? In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 147 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion Wallenberg’s hallmark symptom is sensory--what is it? In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 148 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion Wallenberg’s hallmark symptom is sensory--what is it? In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing pulled to thetoward ipsilateral the lesion face side, and contralateral body or away from it? TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 149 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion Wallenberg’s hallmark symptom is sensory--what is it? In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing pulled to thetoward ipsilateral the lesion face side, and contralateral body or away from it? TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 150 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome Speaking of lateropulsion: Wallenberg pts often manifest something called ocular lateropulsion. What are the findings in this condition? SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? --Lateral-gaze movements toward the lesion side are notably faster than bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion are lateral movements toward the contralateral side --During vertical saccades, the eyes will move toward the lesion side Wallenberg’s hallmark symptom is sensory--what is it? --When the pt is not fixating a visual target (eg, during eye closure), the eyes In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? will move into lateral gaze toward the lesion side TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 151 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome Speaking of lateropulsion: Wallenberg pts often manifest something called Speaking of disequilibrium:ocular lateropulsion Wallenberg pts. What often are c/o thefeeling findings like theirin this condition? Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion?slower --Lateral-gaze movements toward the lesion side are notably fav fasterster than bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion are lateral movements toward the contralateral side --During vertical saccades, the eyes will move toward the lesion side Wallenberg’s hallmark symptom is sensory--what is it? --When the pt is not fixating a visual target (eg, during eye closure), the eyes In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? will move into lateral gaze toward the lesion side TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 152 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome Speaking of lateropulsion: Wallenberg pts often manifest something called ocular lateropulsion. What are the findings in this condition? SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? --Lateral-gaze movements toward the lesion side are notably faster than bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion are lateral movements toward the contralateral side --During vertical saccades, the eyes will move toward the lesion side Wallenberg’s hallmark symptom is sensory--what is it? --When the pt is not fixating a visual target (eg, during eye closure), the eyes In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? will move into lateral gaze toward the lesion side TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 153 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome Speaking of lateropulsion: Wallenberg pts often manifest something called ocular lateropulsion. What are the findings in this condition? SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? --Lateral-gaze movements toward the lesion side are notably faster than bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion are lateral movements toward the contralateral side toward v --During vertical saccades, the eyes will move towardaway the lesion side Wallenberg’s hallmark symptom is sensory--what is it? from --When the pt is not fixating a visual target (eg, during eye closure), the eyes In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? will move into lateral gaze toward the lesion side TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 154 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome Speaking of lateropulsion: Wallenberg pts often manifest something called ocular lateropulsion. What are the findings in this condition? SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? --Lateral-gaze movements toward the lesion side are notably faster than bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion are lateral movements toward the contralateral side --During vertical saccades, the eyes will move toward the lesion side Wallenberg’s hallmark symptom is sensory--what is it? --When the pt is not fixating a visual target (eg, during eye closure), the eyes In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? will move into lateral gaze toward the lesion side TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 155 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome Speaking of lateropulsion: Wallenberg pts often manifest something called ocular lateropulsion. What are the findings in this condition? SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? --Lateral-gaze movements toward the lesion side are notably faster than bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion are lateral movements toward the contralateral side --During vertical saccades, the eyes will move toward the lesion side Wallenberg’s hallmark symptom is sensory--what is it? In Wallenberg, do pts--When feel like the their pt is being not fixating puilled a toward visual the target lesion (eg, side, during eye closure), the eyes Loss of pain and temperature sensation to thetoward ipsilateral v face and contralateral body or away from it? will move into lateral gaze towardaway the lesion side from TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 156 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome Speaking of lateropulsion: Wallenberg pts often manifest something called ocular lateropulsion. What are the findings in this condition? SpeakingIs the of Horner disequilibrium: pupil in Wallenberg Wallenberg syndrome pts often ipsi- c/o feeling or contralateral like their to the lesion? --Lateral-gaze movements toward the lesion side are notably faster than bodyIpsilateral is being ‘pulled to one side.’ What is the name for this sensation? Lateropulsion are lateral movements toward the contralateral side --During vertical saccades, the eyes will move toward the lesion side Wallenberg’s hallmark symptom is sensory--what is it? --When the pt is not fixating a visual target (eg, during eye closure), the eyes In Wallenberg,Loss of pain do and pts feeltemperature like their sensationbeing puilled to the toward ipsilateral the lesion face side,and contralateral body or away from it? will move into lateral gaze toward the lesion side TowardBesides it the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 157 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral Wallenberg syndrome is a form of CVA. In that regard: What very common sign/symptom of a CVA is not Wallenberg’s hallmark symptom is sensory--whatlisted is it? here, ie, is not a component of Wallenberg’s? Loss of pain and temperature sensation to theParalysis ipsilateral face and contralateral body

Besides the Horner and sensory findings, what areWhy the no main paralysis signs/symptoms? in Wallenberg’s? --Cerebellar signs: Disequilibrium, ataxia, nystagmus,As in real skew estate, deviation the three most important factors in --Speech and swallowing difficulties CVA are location, location, and location . And with respect to CVA location, the general rule is, events Occlusion of what vessel is implicated in Wallenbergthat affectsyndrome? the lateral brainstem cause sensory loss, The ipsilateral vertebral or (less commonly) posteriornot paralysis inferior cerebellar (aka “stroke artery without paralysis”). 158 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral Wallenberg syndrome is a form of CVA. In that regard: What very common sign/symptom of a CVA is not Wallenberg’s hallmark symptom is sensory--whatlisted is it? here, ie, is not a component of Wallenberg’s? Loss of pain and temperature sensation to theParalysis ipsilateral face and contralateral body

Besides the Horner and sensory findings, what areWhy the no main paralysis signs/symptoms? in Wallenberg’s? --Cerebellar signs: Disequilibrium, ataxia, nystagmus,As in real skew estate, deviation the three most important factors in --Speech and swallowing difficulties CVA are location, location, and location . And with respect to CVA location, the general rule is, events Occlusion of what vessel is implicated in Wallenbergthat affectsyndrome? the lateral brainstem cause sensory loss, The ipsilateral vertebral or (less commonly) posteriornot paralysis inferior cerebellar (aka “stroke artery without paralysis”). 159 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral Wallenberg syndrome is a form of CVA. In that regard: What very common sign/symptom of a CVA is not Wallenberg’s hallmark symptom is sensory--whatlisted is it? here, ie, is not a component of Wallenberg’s? Loss of pain and temperature sensation to theParalysis ipsilateral face and contralateral body

Besides the Horner and sensory findings, what areWhy the no main paralysis signs/symptoms? in Wallenberg’s? --Cerebellar signs: Disequilibrium, ataxia, nystagmus,As in real skew estate, deviation the three most important factors in --Speech and swallowing difficulties CVA are location, location, and location . And with respect to CVA location, the general rule is, events Occlusion of what vessel is implicated in Wallenbergthat affectsyndrome? the lateral brainstem cause sensory loss, The ipsilateral vertebral or (less commonly) posteriornot paralysis inferior cerebellar (aka “stroke artery without paralysis”). 160 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral Wallenberg syndrome is a form of CVA. In that regard: What very common sign/symptom of a CVA is not Wallenberg’s hallmark symptom is sensory--whatlisted is it? here, ie, is not a component of Wallenberg’s? Loss of pain and temperature sensation to theParalysis ipsilateral face and contralateral body

Besides the Horner and sensory findings, what areWhy the no main paralysis signs/symptoms? in Wallenberg’s? --Cerebellar signs: Disequilibrium, ataxia, nystagmus,As in real skew estate, deviation the three most important factors in --Speech and swallowing difficulties CVA are location, location, and location . And with respect to CVA location, the general rule is, events Occlusion of what vessel is implicated in Wallenbergthat affectsyndrome? the lateral brainstem cause sensory loss, The ipsilateral vertebral or (less commonly) posteriornot paralysis inferior cerebellar (aka “stroke artery without paralysis”). 161 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral Wallenberg syndrome is a form of CVA. In that regard: What very common sign/symptom of a CVA is not Wallenberg’s hallmark symptom is sensory--whatlisted is it? here, ie, is not a component of Wallenberg’s? Loss of pain and temperature sensation to theParalysis ipsilateral face and contralateral body

Besides the Horner and sensory findings, what areWhy the no main paralysis signs/symptoms? in Wallenberg’s? --Cerebellar signs: Disequilibrium, ataxia, nystagmus,As in real skew estate, deviation the three most important factors in --Speech and swallowing difficulties CVA are location, location, and location . And with respect to CVA location, the general rule is, events Occlusion of what vessel is implicated in Wallenbergthat affectsyndrome? the lateral brainstem cause sensory loss, The ipsilateral vertebral or (less commonly) posteriornot paralysis inferior cerebellar (aka “stroke artery without paralysis”). 162 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral Wallenberg syndrome is a form of CVA. In that regard: What very common sign/symptom of a CVA is not Wallenberg’s hallmark symptom is sensory--whatlisted is it? here, ie, is not a component of Wallenberg’s? Loss of pain and temperature sensation to theParalysis ipsilateral face and contralateral body

Besides the Horner and sensory findings, what areWhy the no main paralysis signs/symptoms? in Wallenberg’s? --Cerebellar signs: Disequilibrium, ataxia, nystagmus,As in real skew estate, deviation the three most important factors in --Speech and swallowing difficulties CVA are location, location, and location . And with respect to CVA location, the general rule is, events Occlusion of what vessel is implicated in Wallenbergthat affectsyndrome? the lateral brainstem cause sensory loss, The ipsilateral vertebral or (less commonly) posteriornot paralysis inferior cerebellar (aka “stroke artery without paralysis”). 163 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral Wallenberg syndrome is a form of CVA. In that regard: What very common sign/symptom of a CVA is not Wallenberg’s hallmark symptom is sensory--whatlisted is it? here, ie, is not a component of Wallenberg’s? Loss of painHence and Wallenberg’stemperature sensation noneponymous to theParalysis ipsilateral name face and contralateral body

Besides the Horner and sensory findings, what areWhy the no main paralysis signs/symptoms? in Wallenberg’s? --Cerebellar signs: Disequilibrium, ataxia, nystagmus,As in real skew estate, deviation the three most important factors in --Speech and swallowing difficulties CVA are location, location, and location . And with respect to CVA location, the general rule is, events Occlusion of what vessel is implicated in Wallenbergthat affectsyndrome? the lateral brainstem cause sensory loss, The ipsilateral vertebral or (less commonly) posteriornot paralysis inferior cerebellar (aka “stroke artery without paralysis”).

No question—proceed when ready 164 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 165 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 166 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body What mechanism is typically responsible for occluding the vessel in: Besides the--An Horner older vasculopath?and sensory findings, what are the main signs/symptoms? --Cerebellar--A signs:young Disequilibrium,adult? ataxia, nystagmus, skew deviation --Speech --Aand pt swallowing with valvular difficulties dz, or arrythmia?

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 167 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body What mechanism is typically responsible for occluding the vessel in: Besides the--An Horner older vasculopath?and sensory findings, Atherosclerosis what are the main signs/symptoms? --Cerebellar--A signs:young Disequilibrium,adult? ataxia, nystagmus, skew deviation --Speech --Aand pt swallowing with valvular difficulties dz, or arrythmia?

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 168 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body What mechanism is typically responsible for occluding the vessel in: Besides the--An Horner older vasculopath?and sensory findings, Atherosclerosis what are the main signs/symptoms? --Cerebellar--A signs:young Disequilibrium,adult? ataxia, nystagmus, skew deviation --Speech --Aand pt swallowing with valvular difficulties dz, or arrythmia?

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 169 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body What mechanism is typically responsible for occluding the vessel in: Besides the--An Horner older vasculopath?and sensory findings, Atherosclerosis what are the main signs/symptoms? --Cerebellar--A signs:young Disequilibrium,adult? Dissection ataxia, nystagmus, skew deviation --Speech --Aand pt swallowing with valvular difficulties dz, or arrythmia?

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 170 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body What mechanism is typically responsible for occluding the vessel in: Besides the--An Horner older vasculopath?and sensory findings, Atherosclerosis what are the main signs/symptoms? --Cerebellar--A signs:young Disequilibrium,adult? Dissection ataxia, nystagmus, skew deviation --Speech --Aand pt swallowing with valvular difficulties dz, or arrythmia?

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 171 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

What is the noneponymous name for Wallenberg syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body What mechanism is typically responsible for occluding the vessel in: Besides the--An Horner older vasculopath?and sensory findings, Atherosclerosis what are the main signs/symptoms? --Cerebellar--A signs:young Disequilibrium,adult? Dissection ataxia, nystagmus, skew deviation --Speech --Aand pt swallowing with valvular difficulties dz, or arrythmia? Embolism

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 172 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

Does Wallenberg carry a good, or poor prognosis? WhatGood--most is the noneponymous pts recover with name minimal for Wallenberg sequelae syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 173 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central

Does Wallenberg carry a good, or poor prognosis? WhatGood--most is the noneponymous pts recover with name minimal for Wallenberg sequelae syndrome? Lateral medullary syndrome

Is the Horner pupil in Wallenberg syndrome ipsi- or contralateral to the lesion? Ipsilateral

Wallenberg’s hallmark symptom is sensory--what is it? Loss of pain and temperature sensation to the ipsilateral face and contralateral body

Besides the Horner and sensory findings, what are the main signs/symptoms? --Cerebellar signs: Disequilibrium, ataxia, nystagmus, skew deviation --Speech and swallowing difficulties

Occlusion of what vessel is implicated in Wallenberg syndrome? The ipsilateral vertebral or (less commonly) posterior inferior cerebellar artery 174 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: 175 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic 176 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic

If an adult with a pre- or post-ganglionic Horner’s has no history of trauma, what process should be suspected? An intrathoracic malignancy 177 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic

If an adult with a pre- or post-ganglionic Horner’s has no history of trauma, what process should be suspected? An intrathoracic malignancy 178 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: 179 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic 180 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood

How about in infants (ie, prior to age 12 months)? It is #1

What proportion of peds cancer deaths are due to Nb? 20% 181 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood

How about in infants (ie, prior to age 12 months)? It is #1

What proportion of peds cancer deaths are due to Nb? 20% 182 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood

How about in infants (ie, prior to age 12 months)? It is #1

What proportion of peds cancer deaths are due to Nb? 20% 183 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood

How about in infants (ie, prior to age 12 months)? It is #1

What proportion of peds cancer deaths are due to Nb? 20% 184 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood

How about in infants (ie, prior to age 12 months)? It is #1

What proportion of peds cancer deaths are due to Nb? 20% 185 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood

How about in infants (ie, prior to age 12 months)? It is #1

What proportion of peds cancer deaths are due to Nb? 20% 186 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitor cell that gives rise to neuron and related cells It is #1

What proportion of peds cancer deaths are due to Nb? 20% 187 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitor cell that gives rise to neuron and related cells It is #1

What proportion of peds cancer deaths are due to Nb? 20% 188 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitor cell that gives rise to neuron and related cells It is #1

What proportion of peds cancer deaths are due to Nb? 20% Sympathetic Adrenal- chain neurons? medulla? cells

Which ‘neurons’ and ‘related cells’ are involved in Nb, ie, where are the primaries? The sympathetic chain, and the adrenal medulla 189 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitor cell that gives rise to neuron and related cells It is #1

What proportion of peds cancer deaths are due to Nb? 20% Sympathetic Adrenal- chain neurons medulla cells

Which ‘neurons’ and ‘related cells’ are involved in Nb, ie, where are the primaries? The sympathetic chain, and the adrenal medulla 190 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitor cell that gives rise to neuron and related cells It is #1

What proportion of peds cancer deaths are due to Nb? 20% Sympathetic Adrenal- chain neurons??medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 191 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitor cell that gives rise to neuron and related cells It is #1

What proportion of peds cancer deaths are due to Nb? 20% Sympathetic Adrenal- chain neurons! medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 192 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitor cell that gives rise to neuron and related cells It is #1

What proportion of peds cancer deaths are due to Nb? 20% Sympathetic Adrenal- chain neurons! medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 193 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

Primary tumor in sympathetic chain Horner syndrome 2ndry to Nb 194 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 -- -- What proportion of peds cancer deaths are due to Nb? -- 20% Sympathetic Adrenal- chain neurons medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 195 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosis (aka racoon eyes ) --Proptosis What proportion of peds cancer deaths are due to Nb? --Opsoclonus 20% Sympathetic Adrenal- chain neurons medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 196 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosis (aka racoon eyes ) --Proptosis What proportion of peds cancer deaths are due to Nb? --Opsoclonus 20% Sympathetic Adrenal- chain neurons medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 197 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosis (akaWhat racoon process eyes leads ) to ecchymosis and/or proptosis? --Proptosis Orbital metastasis What proportion of peds cancer deaths are due to Nb? --Opsoclonus 20% Sympathetic Adrenal- chain neurons medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 198 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosis (akaWhat racoon process eyes leads ) to ecchymosis and/or proptosis? --Proptosis Orbital metastasis What proportion of peds cancer deaths are due to Nb? --Opsoclonus 20% Sympathetic Adrenal- chain neurons medulla cells

Of the twoWhich sites, ‘neurons’ which c anand produce ‘related a ce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 199 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

Nb: ‘Raccoon eyes’ 200 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

Nb: Proptosis 201 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosisWhat (aka is opsoclonus racoon ?eyes ) --Proptosis A saccadic intrusion characterized by multivectorial, What proportion of peds cancer deaths are due to Nb? --Opsoclonus large-amplitude movements 20% Sympathetic Adrenal- chain neurons medulla cells Is opsoclonus secondary to orbital metastasis, like ecchymosis and proptosis? Of the twoWhich sites,No—it ‘neurons’ which is a paraneoplasticc anand produce ‘related a phenomenonce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 202 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosisWhat (aka is opsoclonus racoon ?eyes ) --Proptosis A saccadic intrusion characterized by multivectorial, What proportion of peds cancer deaths are due to Nb? --Opsoclonus large-amplitude movements 20% Sympathetic Adrenal- chain neurons medulla cells Is opsoclonus secondary to orbital metastasis, like ecchymosis and proptosis? Of the twoWhich sites,No—it ‘neurons’ which is a paraneoplasticc anand produce ‘related a phenomenonce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 203 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosisWhat (aka is opsoclonus racoon ?eyes ) --Proptosis A saccadic intrusion characterized by multivectorial, What proportion of peds cancer deaths are due to Nb? --Opsoclonus large-amplitude movements 20% Sympathetic Adrenal- chain neurons medulla cells Is opsoclonus secondary to orbital metastasis, like ecchymosis and proptosis? Of the twoWhich sites,No—it ‘neurons’ which is a paraneoplasticc anand produce ‘related a phenomenonce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 204 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosisWhat (aka is opsoclonus racoon ?eyes ) --Proptosis A saccadic intrusion characterized by multivectorial, What proportion of peds cancer deaths are due to Nb? --Opsoclonus large-amplitude movements 20% Sympathetic Adrenal- chain neurons medulla cells Is opsoclonus secondary to orbital metastasis, like ecchymosis and proptosis? Of the twoWhich sites,No—it ‘neurons’ which is a paraneoplasticc anand produce ‘related a phenomenonce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 205 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic

Where does Nb rank as a cause of cancer in childhood? It is the most common cause of extracranial solid cancer (ie, not leukemia) in childhood The cancerous cell in NB—the neuroblast—what is it? How about in infants (ie, prior to age 12 months)? It is the progenitorNb is notorious cell that for givesthree riseother to ophthal neuronmicand manifestations—what related cells are they? It is #1 --Periorbital ecchymosisWhat (aka is opsoclonus racoon ?eyes ) --Proptosis A saccadic intrusion characterized by multivectorial, What proportion of peds cancer deaths are due to Nb? --Opsoclonus large-amplitude movements 20% Sympathetic Adrenal- chain neurons medulla cells Is opsoclonus secondary to orbital metastasis, like ecchymosis and proptosis? Of the twoWhich sites,No—it ‘neurons’ which is a paraneoplasticc anand produce ‘related a phenomenonce Hornerlls’ are syndrome? involved in Nb, The sympatheticie, where chain are the (provided primaries? the tumor is in the cervical portion) The sympathetic chain, and the adrenal medulla 206 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: 207 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic 208 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 209 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 210 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 211 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 212 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 213 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 214 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 215 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissue disorders; eg, Marfan’s and Ehler-Danlos

Is carotid-artery dissection always associated with trauma? No, it can occur spontaneously

Name a classic cause of ‘iatrogenic’ (I’m using the term loosely here) carotid-artery dissection: Cervical-spine manipulation by a chiropractor 216 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg, Marfan’s what is the and first Ehler-Danlos step in management? Emergent neuroimaging Is carotid-artery dissection always associated with trauma? What imaging study should be ordered? No,Angiography--either it can occur spontaneously CTA or MRA

NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 217 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg, Marfan’s what is the and first Ehler-Danlos step in management? Emergent neuroimaging Is carotid-artery dissection always associated with trauma? What imaging study should be ordered? No,Angiography--either it can occur spontaneously CTA or MRA

NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 218 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg, Marfan’s what is the and first Ehler-Danlos step in management? Emergent neuroimaging Is carotid-artery dissection always associated with trauma? What imaging study should be ordered? No,Angiography--either it can occur spontaneously CTA or MRA

NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 219 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg, Marfan’s what is the and first Ehler-Danlos step in management? Emergent neuroimaging Is carotid-artery dissection always associated with trauma? What imaging study should be ordered? No,Angiography--either it can occur spontaneously CTA or MRA

NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 220 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

Carotid dissection 221 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg, Marfan’s what is the and first Ehler-Danlos step in management? Emergent neuroimaging Is carotid-artery dissection always associated with trauma? What imaging study should be ordered? No,Angiography--either it can occur spontaneously CTA or MRA

NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 222 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg, Marfan’s what is the and first Ehler-Danlos step in management? Emergent neuroimaging Is carotid-artery dissection always associated with trauma? What imaging study should be ordered? No,Angiography--either it can occur spontaneously CTA or MRA

NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 223 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg,Imaging Marfan’s what is mustthe and first extendEhler-Danlos step infrom management? where to where; ie, what Emergent neuroimaging anatomic structures delimit the region that needs to Is carotid-artery dissection alwaysbe associated imaged? with trauma? What imaging study should be ordered? No, it can occur spontaneously It must extend from the apex of the lung up to the Angiography--either CTA or MRACircle of Willis NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 224 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic

What percent of carotid-artery dissection pts will present with a Horner? About 60

What systemic conditions predispose to carotid-artery dissection? Connective-tissueIf carotid dissection disorders; is suspected, eg,Imaging Marfan’s what is mustthe and first extendEhler-Danlos step infrom management? where to where; ie, what Emergent neuroimaging anatomic structures delimit the region that needs to Is carotid-artery dissection alwaysbe associated imaged? with trauma? What imaging study should be ordered? No, it can occur spontaneously It must extend from the apex of the lung up to the Angiography--either CTA or MRACircle of Willis NameWhat a aboutclassic carotid cause doppler of ‘iatrogenic’ study--wouldn’t (I’m using that thesuffice? term loosely here) carotid-arteryNo, it is not adequatedissection: Cervical-spine manipulation by a chiropractor 225 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: 226 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic 227 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic

What is a Pancoast tumor? A mass at or near the superior sulcus (=apex) of the lung 228 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic

What is a Pancoast tumor? A mass at or near the superior sulcus (=apex) of the lung 229 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

Pancoast tumor 230 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic HA = ‘Headache’ (but we’ll also use it to  Cluster HA: mean something else a few slides hence) 231 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic 232 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic

Is Horner syndrome a common finding in cluster HA? Yes--estimates run as high as 50%

So, Horner’s + HA cinches a diagnosis of cluster HA, then? No! Dissection of the internal carotid artery is also associated with HA, face and/or eye pain 233 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic

Is Horner syndrome a common finding in cluster HA? Yes--estimates run as high as 50%

So, Horner’s + HA cinches a diagnosis of cluster HA, then? No! Dissection of the internal carotid artery is also associated with HA, face and/or eye pain 234 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic

Is Horner syndrome a common finding in cluster HA? Yes--estimates run as high as 50%

So, Horner’s + HA cinches a diagnosis of cluster HA, then? No! Dissection of the internal carotid artery is also associated with HA, face and/or eye pain 235 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic

Is Horner syndrome a common finding in cluster HA? Yes--estimates run as high as 50%

So, Horner’s + HA cinches a diagnosis of cluster HA, then? No! Dissection of the internal carotid artery is also associated with HA, face and/or eye pain 236 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic

Is Horner syndrome a common finding in cluster HA? Yes--estimates run as high as 50%

So, Horner’s + HA cinches a diagnosis of cluster HA, then? No! Dissection of the internal carotid artery is also associated with HA, face and/or eye pain Acute-onset Horner’s + facial/neck pain is an internal carotid dissection until proven otherwise, and must be worked up emergently! 237 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: 238 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic 239 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

Shoulder dystocia is another cause of congenital Horner’s. Look for a hx of complicated birth, along with signs and symptoms of brachial-plexus injury/dysfunction.

Forceps delivery/shoulder dystocia 240 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, a positive response indicates a pre-ganglionic Horners. 241 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, a positive response indicates a pre-ganglionic Horners. 242 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact. Why is this? That is, what is it about cocaine drops that allows this assertion to be made? Cocaine’sHow does mechanism one differentiate of action betw is toeen block a pre- the andre-uptake post-ganglionic of norepinephrine. Horners? Thus, it can dilate the pupil onlyHydroxyamphetamine if norepinephrine is alread (HA)y droppresent testing. in the HAneuromuscular drops will eliminate junctions anisocoria of the pupillary if the post-ganglionic dilator muscle. And norepinephrineneuron is intact; will therefore,be present a inpositive the junctions response only indicates if the pos a t-ganglionicpre-ganglionic fibers Horners. are being prompted to release it by an intact sympathetic chain--dysfunction anywhere in the chain will result in the absence of norepinephrine in the neuromuscular junction, and therefore a positive (ie, a failure to dilate) cocaine test. 243 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact. Why is this? That is, what is it about cocaine drops that allows this assertion to be made? Cocaine’sHow does mechanism one differentiate of action betw is toeen block a pre- the and re-uptake post-ganglionic of norepinephrine. Horners? Thus, it can dilate the pupil onlyHydroxyamphetamine if norepinephrine is alread (HA)y droppresent testing. in the HAneuromuscular drops will eliminate junctions anisocoria of the pupillary if the post-ganglionic dilator muscle. And norepinephrineneuron is intact; will therefore,be present a inpositive the junctions response only indicates if the pos a t-ganglionicpre-ganglionic fibers Horners. are being prompted to release it by an intact sympathetic chain. Dysfunction anywhere in the chain will result in the absence of norepinephrine in the neuromuscular junction, and therefore a positive (ie, a failure to dilate) cocaine test. 244 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact. Why is this? That is, what is it about cocaine drops that allows this assertion to be made? Cocaine’sHow does mechanism one differentiate of action betw is toeen block a pre- the and re-uptake post-ganglionic of norepinephrine. Horners? Thus, it can dilate the pupil onlyHydroxyamphetamine if norepinephrine is alread (HA)y droppresent testing. in the HAneuromuscular drops will eliminate junctions anisocoria of the pupillary if the post-ganglionic dilator muscle. And norepinephrineneuron is intact; will therefore,be present a inpositive the junctions response only indicates if the pos a t-ganglionicpre-ganglionic fibers Horners. are being prompted to release it by an intact sympathetic chain. Dysfunction anywhere in the chain will result in the absence of norepinephrine in the neuromuscular junction, and therefore a positive (ie, a failure to dilate) cocaine test. 245 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact. Why is this? That is, what is it about cocaine drops that allows this assertion to be made? Cocaine’sHow does mechanism one differentiate of action betw is toeen block a pre- the and re-uptake post-ganglionic of norepinephrine. Horners? Thus, it can dilate the pupil onlyHydroxyamphetamine if norepinephrine is alread (HA)y droppresent testing. in the HAneuromuscular drops will eliminate junctions anisocoria of the pupillary if the post-ganglionic dilator muscle. And norepinephrineneuron is intact; will therefore,be present a inpositive the junctions response only indicates if the pos a t-ganglionicpre-ganglionic fibers Horners. are being prompted to release it by an intact sympathetic chain. Dysfunction anywhere in the chain will result in the absence of norepinephrine in the neuromuscular junction, and therefore a positive (ie, a failure to dilate) cocaine test. 246 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact. Why is this? That is, what is it about cocaine drops that allows this assertion to be made? Cocaine’sHow does mechanism one differentiate of action betw is toeen block a pre- the and re-uptake post-ganglionic of norepinephrine. Horners? Thus, it can dilate the pupil onlyHydroxyamphetamine if norepinephrine is alread (HA)y droppresent testing. in the HAneuromuscular drops will eliminate junctions anisocoria of the pupillary if the post-ganglionic dilator muscle. And norepinephrineneuron is intact; will therefore,be present a inpositive the junctions response only indicates if the pos a t-ganglionicpre-ganglionic fibers Horners. are being prompted to release it by an intact sympathetic chain. Dysfunction anywhere in the chain will result in the absence of norepinephrine in the neuromuscular junction, and therefore a positive (ie, a failure to dilate) cocaine test. 247 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

Positive cocaine test (failure of anisocoria to resolve) 248 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, a positive response indicates a pre-ganglionic Horners. 249 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 250 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs. PancoastAnd norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are healthy--if these neurons are damaged--ie, if the pt has a post-ganglionic Horner syndrome--the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye--the postganglionicCocaine drop fibers testing. are Cocaineintact for will both, essentially so both willeliminate dilate inanisocoria response if to and HA. only Thus, if the before sympathetic HA testing chain is performed,is intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 251 For each condition, identify the type of Horner syndrome Q/A(central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the causepostganglionic release? impede uptake? fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs. PancoastAnd norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are healthy. If these neurons are damaged--ie, if the pt has a post-ganglionic Horner syndrome--the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye--the postganglionicCocaine drop fibers testing. are Cocaineintact for will both, essentially so both willeliminate dilate inanisocoria response if to and HA. only Thus, if the before sympathetic HA testing chain is performed,is intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 252 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs. PancoastAnd norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are healthy. If these neurons are damaged--ie, if the pt has a post-ganglionic Horner syndrome--the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye--the postganglionicCocaine drop fibers testing. are Cocaineintact for will both, essentially so both willeliminate dilate inanisocoria response if to and HA. only Thus, if the before sympathetic HA testing chain is performed,is intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 253 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs, Pancoastand norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are intact. If these neurons are damaged--ie, if the pt has a post-ganglionic Horner syndrome--the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in response to HA. ClusterOn the other hand, HA: in a central Post-ganglionic or pre-ganglionic Horners, the post-ganglionic fibers are intact, and therefore Forceps capable of releasing delivery: norepinephrine Pre- when stimulated or post-ganglionic to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye--the postganglionicCocaine drop fibers testing. are Cocaineintact for will both, essentially so both willeliminate dilate inanisocoria response if to and HA. only Thus, if the before sympathetic HA testing chain is performed,is intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 254 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs, Pancoastand norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are intact. If these neurons are damaged—ie, if the pt has a post-ganglionic Horner syndrome—the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye--the postganglionicCocaine drop fibers testing. are Cocaineintact for will both, essentially so both willeliminate dilate inanisocoria response if to and HA. only Thus, if the before sympathetic HA testing chain is performed,is intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 255 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs, Pancoastand norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are intact. If these neurons are damaged—ie, if the pt has a post-ganglionic Horner syndrome—the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye--the postganglionicCocaine drop fibers testing. are Cocaineintact for will both, essentially so both willeliminate dilate inanisocoria response if to and HA. only Thus, if the before sympathetic HA testing chain is performed,is intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 256 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

A. Before drops administered (suspected right Horner syndrome). B. After drops administered. Note the dilation of both pupils. This indicates an intact 3rd-order, postganglionic neuron and localizes the lesion to the 1st-order (central) or 2nd-order (preganglionic) neuron.

HA test 257 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs, Pancoastand norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are intact. If these neurons are damaged—ie, if the pt has a post-ganglionic Horner syndrome—the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye--the postganglionicCocaine drop fibers testing. are Cocaineintact for will both, essentially so both willeliminate dilate inanisocoria response if to and HA. only Thus, if the before sympathetic HA testing chain is performed,is intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 258 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs, Pancoastand norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are intact. If these neurons are damaged—ie, if the pt has a post-ganglionic Horner syndrome—the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye (theCocaine postganglionic drop testing. fibers Cocaine are intact will for essentially both, so both eliminate will di lateanisocoria in responseif and toonly HA. if Thus,the sympathetic before HA chaintesting isis performed, intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 259 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic And why is this? That is, what is it about HA drops that allows this assertion to be made? HA’s mechanismInternal of action carotid is to stimulate dissection: the postganglionic fibers Post-ganglionic to release norepinephrine into the neuromuscular junction. Thus, HA can dilate the pupil only if norepinephrine is in fact present in these bulbs, Pancoastand norepinephrine willtumor: be present inPre-ganglionic these bulbs only if the post-ganglionic fibers are intact. If these neurons are damaged—ie, if the pt has a post-ganglionic Horner syndrome—the degenerated terminal bulbs will have little or no norepinephrine to release, and thus the pupil will dilate poorly or not at all in responseCluster to HA. On the HA: other hand, Post-ganglionic in a central or pre-ganglionic Horners, the post-ganglionic fibers are intact, Forcepsand therefore capable delivery: of releasing norepinephrine Pre- or when post-ganglionic stimulated to do so by HA. Why must cocaine drop testing precede HA drop testing? HAHow drops does cannot one ‘prove’ distinguish a patient between has a a Horners? preganglionic/central Horner syndrome and a non-Horner eye (theCocaine postganglionic drop testing. fibers Cocaine are intact will for essentially both, so both eliminate will di lateanisocoria in response if and toonly HA. if Thus,the sympathetic before HA chaintesting isis performed, intact. the cocaine test is needed to establish that a Horner syndrome is present.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners (assuming cocaine testing has established that a Horner syndrome is present). 260 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. What is the brand name for HA drops? Paradrine 261 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. What is the brand name for HA drops? Paredrine 262 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck trauma Internal from forceps delivery?carotid dissection: Post-ganglionic Transynaptic degeneration. Pre-ganglionic fiber loss prior to age 10 years leads to transynaptic degenerationPancoast of the post-ganglionic tumor: fibers. Pre-ganglionic Because of this, the HA response would be negative for a pre- or post-ganglionic lesion originating with a forceps injury. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response.  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 263 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck trauma Internal from forceps delivery?carotid dissection: Post-ganglionic Transynaptic degeneration. Pre-ganglionic fiber loss prior to age 10 years leads to transynaptic degenerationPancoast of the post-ganglionic tumor: fibers. Pre-ganglionic Because of this, the HA response would be negative for a pre- or post-ganglionic lesion originating with a forceps injury. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response.  Forceps delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 264 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s-- (HA) drophow testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 265 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s-- (HA) drophow testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 266 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s-- (HA) drophow testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 267 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s-- (HA) drophow testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 268 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s-- (HA) drophow testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 269 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s-- (HA) drophow testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 270 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s--how (HA) drop testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 271 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s--how (HA) drop testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 272 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s--how (HA) drop testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 273 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic Why will HA drop testing be non-localizing if the Horner syndrome is secondary to a history of neck Internal trauma from forceps carotid delivery ?dissection: Post-ganglionic WhatTransynaptic implications degeneration does this hold. forPre-ganglionic managing Horner fiber syndromeloss prior into children?age 10 years leads to transynaptic Itdegeneration impliesPancoast one cannot of the rely post-ganglionic on tumor:HA testing fibers.to differentiate Pre-ganglionic Because betwe of this,en pre- the andHA responsepost-ganglionic would Horner’s be negative in children. for a Becausepre- or post-ganglionic of this, drop testing lesion cannot originating be relied with upon a forcepsto rule out injury. neuroblastoma. After age 10 years, loss of the pre- ganglionicCluster fibers does HA: not result Post-ganglionic in transynaptic loss, thus preserving the HA response. Which is more likely to be associated with neuroblastoma: A congenital Horner’s, or one acquired in infancy or early childhood?Forceps delivery: Pre- or post-ganglionic Acquired Horner’s How does one ‘prove’ a patient has a Horners? CocaineAbsent a cleardrop trauma testing. history, Cocaine how willshould essentially one work eliminate up a Horner’s anisocoria acquired if and in infancy/early only if the sympathetic childhood? chain isIn intact.addition to a thorough H&P by a pediatrician, urine catecholamine (VMA, etc) testing should be undertaken. Careful consideration should be given to imaging the entire sympathetic chain as well. How does one differentiate between a pre- and post-ganglionic Horners? HydroxyamphetamineWhat about a congenital Horner’s--how (HA) drop testing. should HAthat drops be worked will eliminate up? anisocoria if the post-ganglionic neuronThere is is less intact; consensus therefore, on thispupillary score. dilation If other stigmataindicates of a birpreth-ganglionic/central trauma are present Horners.(eg, brachial plexus injury), a workup is unnecessary. Absent such a history, relatively low-cost and low-risk maneuvers such as a thorough H&P and urine catecholamine testing are reasonable to undertake. It is less certain that imaging of the entire sympathetic chain is warranted. 274 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a nonselective tumor: alpha-adrenergic Pre-ganglionic agonist

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 275 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?   WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a nonselective tumor: alpha-adrenergic Pre-ganglionic agonist

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 276 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a nonselective tumor: alpha-adrenergic Pre-ganglionic agonist

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 277 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a nonselective tumor: alpha-adrenergic Pre-ganglionic agonist

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 278 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a nonselective tumor: alpha-adrenergic Pre-ganglionic agonist

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 279 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a nonselective tumor: alpha-adrenergic Pre-ganglionic agonist

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 280 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a nonselective tumor: alpha-adrenergic Pre-ganglionic agonist

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 281 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a selective  -adrenergictumor: agonist Pre-ganglionic

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 282 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a selective  -adrenergictumor: agonist Pre-ganglionic

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation? Alpha  Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 283 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) testingPre- or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for?  InternalAn ocular hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  PancoastIt is a selective  -adrenergictumor: agonist Pre-ganglionic

 ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 284 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 285 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

How does one ‘prove’ a patient has a Horners? Cocaine drop testing. Cocaine will essentially eliminate anisocoria if and only if the sympathetic chain is intact.

How does one differentiate between a pre- and post-ganglionic Horners? Hydroxyamphetamine (HA) drop testing. HA drops will eliminate anisocoria if the post-ganglionic neuron is intact; therefore, pupillary dilation indicates a pre-ganglionic/central Horners. 286 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

A. Before drops administered (suspected left Horner syndrome). B. After drops administered. Note the slight “reversal of anisocoria” in the left eye

Apraclonidine testing 287 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. How does one differentiate between a pre- and post-ganglionic Horners? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 288 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. How does one differentiate between a pre- and post-ganglionic Horners? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 289 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. HowHow long does after one the differentiate Horner-inciting betw injuryeen a to pre- the andsympathetic post-ganglionic pathway Horners? does it take for denervation supersensitivity to develop? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? In general, a few days (case reports exist of it occurring in as little as a few hours) Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 290 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. HowHow long does after one the differentiate Horner-inciting betw injuryeen a to pre- the andsympathetic post-ganglionic pathway Horners? does it take for denervation supersensitivity to develop? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? In general, a few days (case reports exist of it occurring in as little as a few hours) Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 291 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. How does one differentiate between a pre- and post-ganglionic Horners? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 292 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. How does one differentiate between a pre- and post-ganglionic Horners? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 293 For each condition, identify the type of Horner syndrome (central, pre-ganglionic or post-ganglionic) with which it is associated

A. Before drops administered (suspected left Horner syndrome). B. After drops administered. Note the slight “reversal of anisocoria” in the left eye and the resolution of ptosis.

Apraclonidine testing 294 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. How does one differentiate between a pre- and post-ganglionic Horners? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 295 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic

WhatHow is does the physiological one ‘prove’ a basispatient of hasanisocoria a Horners? reversal in response to apraclonidine in Horner syndrome? DenervationCocaine drop supersensitivity testing. Cocaine. Horner will essentially syndrome eliminate results in anisocoria upregulation if and of alpha only 1ifreceptorsthe sympathetic on the chainpupillary dilatoris intact. muscle of the affected eye; therefore, this eye will exhibit a stronger response to apraclonidine instillation, and will thus dilate to a degree greater than the normal fellow eye. How does one differentiate between a pre- and post-ganglionic Horners? In Hydroxyamphetamineaddition to anisocoria reversal, (HA) drop what testing. other respo HA dropsnse to will apraclonidine eliminate anisocoria is sugge stiveif the of post-ganglionic Horner syndrome? Resolutionneuron is ofintact; ptosis therefore, pupillary dilation indicates a pre-ganglionic/central Horners.

What is the pathophysiology of ptosis in Horner syndrome? The absence of sympathetic stimulation to Müller’s muscle of the lid produces a mild ptosis 296 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic 297 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 Neuroblastoma:What is apraclonidine commonly Pre-ganglionic used for? HowInternalAn is ocularapraclonidine hypotensive, carotid used init isdiagnosing usdissection:ed to blunt Horner perioperative syndrome? Post-ganglionic pressure spikes It is instilled in both eyes. If the anisocoria reverses, the Horners is confirmed. What is its mechanism of action?  Pancoast tumor: Pre-ganglionic HowIt isis apraclonidinea nonselective used alpha-adrenergic to differentiate agonist between a pre- and post-ganglionic Horners? It can’t  ClusterWhich alpha receptorsHA: Post-ganglionic are involved in pupil dilation?   Forceps1 delivery: Pre- or post-ganglionic 298 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 I’mNeuroblastoma:What out ofis apraclonidineapraclonidine. commonly Can I usePre-ganglionic usedbrimonidine for? instead?  I’mInternalAn afraid ocular not hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  WhyPancoast not? Aren’t they tumor: very similar Pre-ganglionic meds? ForIt ispurposes a nonselective of Horner alpha-adrenergic drop-testing, not agonist similar enough. While apraclonidine preferentially stimulates the  receptor, it still provides some stimulation of the  ClusterWhich alpha receptorsHA: Post-ganglionic are involved2 in pupil dilation? 1 receptors of the dilator muscles. In contrast, bromonidine is a highly-selective Alpha1  Forceps2 agonist, and asdelivery: such provides littlePre- to noor 1 stimulation, post-ganglionic and therefore will not induce pupil dilation. 299 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 I’mNeuroblastoma:What out ofis apraclonidineapraclonidine. commonly Can I usePre-ganglionic usedbrimonidine for? instead?  I’mInternalAn afraid ocular not hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  WhyPancoast not? Aren’t they tumor: very similar Pre-ganglionic meds? ForIt ispurposes a nonselective of Horner alpha-adrenergic drop-testing, not agonist similar enough. While apraclonidine preferentially stimulates the  receptor, it still provides some stimulation of the  ClusterWhich alpha receptorsHA: Post-ganglionic are involved2 in pupil dilation? 1 receptors of the dilator muscles. In contrast, bromonidine is a highly-selective Alpha1  Forceps2 agonist, and asdelivery: such provides littlePre- to noor 1 stimulation, post-ganglionic and therefore will not induce pupil dilation. 300 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 I’mNeuroblastoma:What out ofis apraclonidineapraclonidine. commonly Can I usePre-ganglionic usedbrimonidine for? instead?  I’mInternalAn afraid ocular not hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  WhyPancoast not? Aren’t they tumor: very similar Pre-ganglionic meds? ForIt ispurposes a nonselective of Horner alpha-adrenergic drop-testing, not agonist similar enough. While apraclonidine preferentially stimulates the  receptor, it still provides some stimulation of the  ClusterWhich alpha receptorsHA: Post-ganglionic are involved2 in pupil dilation? 1 receptors of the dilator muscles. In contrast, bromonidine is a highly-selective Alpha1  Forceps2 agonist, and asdelivery: such provides littlePre- to noor 1 stimulation, post-ganglionic and therefore will not induce pupil dilation. 301 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 I’mNeuroblastoma:What out ofis apraclonidineapraclonidine. commonly Can I usePre-ganglionic usedbrimonidine for? instead?  I’mInternalAn afraid ocular not hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  WhyPancoast not? Aren’t they tumor: very similar Pre-ganglionic meds? ForIt ispurposes a nonselective of Horner alpha-adrenergic drop-testing, not agonist similar enough. While apraclonidine preferentially stimulates the  receptor, it still provides some stimulation of the  ClusterWhich alpha receptorsHA: Post-ganglionic are involved2 in pupil dilation? 1 receptors of the dilator muscles. In contrast, bromonidine is a highly-selective Alpha1  Forceps2 agonist, and asdelivery: such provides littlePre- to noor 1 stimulation, post-ganglionic and therefore will not induce pupil dilation. 302 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

In actuality, cocaine and HA drop testing are rarely performed—why?  WallenbergThese drugs are highly syndrome: controlled substances—difficult Central to acquire and maintain What drop test can be performed in their stead?  NeckApraclonidine trauma: (Iopidine) Pre- testing or post-ganglionic

 I’mNeuroblastoma:What out ofis apraclonidineapraclonidine. commonly Can I usePre-ganglionic usedbrimonidine for? instead?  I’mInternalAn afraid ocular not hypotensive, carotid it is usdissection:ed to blunt perioperative Post-ganglionic pressure spikes What is its mechanism of action?  WhyPancoast not? Aren’t they tumor: very similar Pre-ganglionic meds? ForIt ispurposes a nonselective of Horner alpha-adrenergic drop-testing, not agonist similar enough. While apraclonidine preferentially stimulates the  receptor, it still provides some stimulation of the  ClusterWhich alpha receptorsHA: Post-ganglionic are involved2 in pupil dilation? 1 receptors of the dilator muscles. In contrast, bromonidine is a highly-selective Alpha1  Forceps2 agonist, and asdelivery: such provides littlePre- to noor 1 stimulation, post-ganglionic and therefore will not induce pupil dilation. 303 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

Which drop test differentiates between a pre-ganglionic and central Horners? None. A central Horners is usually apparent by the company it keeps, or by history. 304 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

Which drop test differentiates between a pre-ganglionic and central Horners? None. A central Horners is usually apparent by the company it keeps, or by history. 305 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

Which drop test differentiates between a pre-ganglionic and central Horners? None. A central Horners is usually apparent by the company it keeps, or by history.

What sorts of findings would be associated with a central Horners? Significant neurological impairment including difficulties with speaking,swallowing and/or balance, as well as disordered movements (ie, a Wallenberg-type scenario) 306 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

Which drop test differentiates between a pre-ganglionic and central Horners? None. A central Horners is usually apparent by the company it keeps, or by history.

What sorts of findings would be associated with a central Horners? Significant neurological impairment including difficulties with speaking, swallowing and/or balance, as well as disordered movements (ie, a Wallenberg-type scenario) 307 For each condition, identify the type of Horner syndrome Q (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

Which drop test differentiates between a pre-ganglionic and central Horners? None. A central Horners is usually apparent by the companycompany it it keeps, keeps or, or by by history history..

What history would be associated with a central Horners? Associated history could include significant intracranial events (CVA, tumor, meningitis, a bleed) or a history of significant high C-spine trauma (fracture, dislocation). 308 For each condition, identify the type of Horner syndrome A (central, pre-ganglionic or post-ganglionic) with which it is associated

 Wallenberg syndrome: Central  Neck trauma: Pre- or post-ganglionic  Neuroblastoma: Pre-ganglionic  Internal carotid dissection: Post-ganglionic  Pancoast tumor: Pre-ganglionic  Cluster HA: Post-ganglionic  Forceps delivery: Pre- or post-ganglionic

Which drop test differentiates between a pre-ganglionic and central Horners? None. A central Horners is usually apparent by the companycompany it it keeps, keeps or, or by by history history..

What history would be associated with a central Horners? Associated history could include significant intracranial events (CVA, tumor, meningitis, a bleed) or a history of significant high C-spine trauma (fracture, dislocation). 309 Q

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:

 Headuppermost level needing imaging  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 310 A

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 311 Q

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skullspecific base aspect of head  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 312 A

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 313 Q

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head

 Necknext level needing imaging  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 314 A

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 315 Q

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base

 Internalspecific carotid structure in neck artery (esp. at the skull base)  Paraspinal area  Mediastinum 316 A

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 317 Q

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck

 Uppernext level needing chest imaging  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 318 A

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum 319 Q

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)

 Paraspinalspecific aspect of chest 1area

 Mediastinumspecific aspect of chest 2 320 A

 Unless congenital, and absent a definite trauma history, a Horner syndrome must be worked up with imaging of the:  Head  Neck  Upper chest  …with attention to the:  Skull base  Internal carotid artery (esp. at the skull base)  Paraspinal area  Mediastinum