>>1) did anyone ever see / hear off / read about difference in
> pupillary size with reactive pupils in an otherwise clinically normal
> trauma victim, which signified uncal herniation or other serious
> event ?<<
Of course, you have to first distinguish cases of physiologic anisicoria.=
Generally this is limited to 0.5 mm differnce in pupil size but, more
importantly, the pupillary inequality will be maintained as ambient
lighting conditions change. E.g., relative anisicoria due to oculomotor
nerve palsy will INCREASE in bright lighting conditions. Physiologic
anisocoria will not.
Other than direct trauma to the orbit affecting the ciliary ganglion
(mydiasis) or dissection of a carotid artery causing an ipsilateral
Horner's syndrome (miosis) I am unaware of any other mechanism, excepting=
3rd nerve compression, that can do this.
It has been said, although I can provide no literature reference, that a
3rd nerve palsy in a fully awake patient is NEVER caused by uncal
herniation. I.e., by the time pupillary inequality occurs mentation will =
invariably impaired (in some manner) due to the associated brainstem
Now a *trochlear* nerve palsy characterized, of course, by diplopia in
certain directions of gaze, has been described in blunt head injury. I
have seen a case of this presenting several days later.
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