 It should be on there. All right, so our next talker is going to be Ryan O'Mealia, who's from the University of Oklahoma. And he's going to talk about down and out, again, abdominal-plegic migraine. And usually using that. OK, well thank you for the opportunity to come and speak with you guys. Yes, it's titled Down and Out Again. And so three-year-old girl comes to your office and you see this. This is a representative photo, of course. Not actual. But yeah, there's decreased up gaze, decreased down gaze, and decreased abduction of the right eye. And so yeah, hey, this is pretty good. Third nerve palsy coming in. And so you get history of present illness. And so it's three-year, three-month-old girl with a past medical history of third nerve palsy. It happened about two years ago. And it spontaneously resolved over a few weeks. This time, though, she had, around Thursday, about five days ago, she had a GI illness with some nausea and vomiting. But no fever, no URI, no cough or eye pain, not even a headache, actually. And then by Saturday, so it resolves. And then the parents start to notice the lid drooping over the next day. The eye kind of starts to go down and start to go out. And so she gets some eye wandering. And then they notice the pupils are different sizes. And so they bring her in. And this is where we're at. So looking into the previous episode a little bit more, you see that it presented exactly the same way. Cedricudon said over a few days, progressed to anisocorian strabismus. And then it resolves over a few weeks. It was treated at an outside hospital. And the MRI that they got there read that there was enhancement of a third nerve, contrast enhancement of the third nerve, where it exits from the midbrain right there in the cisternal segment. They said it was consistent with inflammatory neuritis. Probably the most common ideology is just going to be a post-viral neuritis. So continuing on with the history and the findings, past surgical history, medical medications, and all that, all non-contributory, family history, social history, abuse symptoms, all just normal, not really contributing to this. On physical exam, what you should notice right here, anisocoria, and then also you have the restriction of the gaze. On penlight exam, right here, notice she's got the ptosis. And then her vitals are all normal, labs all normal. So getting the MRI and the imaging, what we see is enhancement of the third nerve right as it exits the brainstem. And then even maybe a little bit as it progresses up higher. This is the actual image. This isn't representative. This is the image of the three-year-old girl. And then here's a coronal view of the MRI with contrast. You do see the contrast enhancement of the third nerve. And then even moving back a little bit further, you see it really light up. And this is the read from the radiologist when it's compared to the prior MRI from the other episode. It's the stable thickening right there at the root exit zone of the third nerve. And so for a differential on this, maybe it's just another episode of post-voluneritis. Maybe she's kind of unlucky with that. Or it could be ophthalmoclegic migraine. Other things to definitely rule out when looking at a case like this, you want aneurysm, schwannoma, ptolosahunt, acute demyelinating, encephalomyelopathy, and Miller-Fischer syndrome. All these other ones, you know, the natural history of the aneurysm and the schwannoma is going to be more progressive rather than this episodic. Then ptolosahunt's going to be on the MRI is going to be effect more like a cavernous sinus area. And these would also have other neurologic deficits coming along with them, most likely. And so we'll just continue to talk about this one because it's going to be the most interesting and controversial rather than the post-voluneritis. So for ophthalmoclegic migraine, the epidemiology, it's actually, it's quite rare and it mainly affects children and females. The median age is going to be about eight years old. Signs and symptoms, basically, I mean it's kind of self-explanatory. You've got a headache that's then followed by ophthalmoplegia and it usually takes about, it can be immediate or it can be up to about 14 days. And the headache, many times it has migraine characteristics which actually led to the naming of this. Oftentimes you can get photophobia, phonophobia, nausea, vomiting. These numbers all come from a paper published in 2012 by Gelfand. And then with, as far as the ophthalmoplegia, the most common nerve to be affected is the third cranial nerve, followed by that the sixth cranial nerve. And then sometimes you can get multiple nerves, but when you do have multiple nerves, it's pretty much always that you will have cranial nerve three involvement. Lots of words on this slide. The overall, what I want you to get from this is that this is the description and diagnostic criteria put forth by the International Headache Society in their publication of the International Classification of Headache Disorders. And what's interesting about this is that the evolution of the diagnostic criteria for this has actually mirrored the thinking for the etiology of ophthalmoplegic migraine. The first time, in the first edition, the ICHD-1, it was actually characterized as a migraine variant. And then in the second edition, what they did is they got away from that and they categorized it as a cranial neuralgia. And they still kept the migraine name, it was still called ophthalmoplegic migraine, but, oh, and it also had to be a migraine-like headache. But they were kind of getting away from the migraine a little bit. And then now in this third edition, they've actually completely recategorized it into a cranial neuropathy and they've gotten away from the naming of ophthalmoplegic migraine, it's no one to call that. It's actually called recurrent, painful, ophthalmoplegic neuropathy, much easier to say. But yeah, so it's mirroring the thinking of the etiology on this. And they no longer have to be migraine-like headaches. They actually just have to be unilateral and ipsilateral to where the ophthalmoplegia is gonna occur. And the ophthalmoplegia can occur up to 14 days out. And so where all this controversy is coming from is actually the imaging and how to explain how this imaging abnormality happens along with the clinical characteristics and the imaging abnormality, like we saw in our patients, is this is from the literature. This is a 1998 article. You get this cranial nerve enhancement of the ocular motor nerve right as it exits the midbrain. Here's another one from the literature right there, a coronal section. And this is a reversible enhancement. And so it's just the controversy comes from like, how do we explain this reversible enhancement? And there's kind of two camps from what I found in my research. You get, it's either could be a neuropathy or it could actually be a migraine. And like I was saying, the trend right now is getting away from a migraine and towards a neuropathy. Possibly viral or autoimmune, but the still don't really know what exact is causing it. And then as far as migraine, the thinking behind how a migraine could cause it is that the migraine induces a vasospasm, which then induces ischemia to the third nerve, which then causes a reversible breakdown of the nerve blood barrier, allowing for the contrast to leak out. And this paper was actually published very recently in 2014. And so as you can see, arguments for pro migraine are still very much in process. The big takeaway is that like the jury's still out. We don't know exactly what causes it or how exactly to categorize it. But the good news is for our patients, the treatment remains the same. You still give them steroids. And the prognosis is very good. Most people have a spontaneous resolution of symptoms and the enhancement of the third nerve goes away. And usually it just happens over a few weeks and sometimes they can persist, but that usually happens with recurrent bouts. And so I'll open up the floor to any questions. There's my references. You. Oh, yeah, sorry, yeah. No, that's a good question. I honestly, I don't know what exactly the dosing is or the route of the steroids on that. Yes. Typically what I found in the reading and the literature is that the migraine medications don't help that much and that it is more responsive to steroids. And that there's all these arguments as to like what is the etiology? And that is one of the reasons people often give for it not being a migranous cause. You have to rule that out. That's actually one of the rule criteria for ophthalmophlegic migraine or this RPON. It is a diagnosis of exclusion and so you have to rule that out. That's a great question. If I'm remembering correctly, it's about in the 2012 study by Gelfand, it was about 67% had a history, a personal history of migraine. Family history, there was also, I don't remember the exact number off the top of my head, but yes, there was also a strong family history, which was an argument for migraine. It was attributed to the muscle imbalance. It wasn't a super concerning occurrence. I think it wasn't happening extremely often and the parents were saying, you know, this isn't happening when she's walking. It's just like, you know, whenever she's really running, just maybe we think that she's falling down a little bit more and so, yeah. Good question though.