ABSTRACT

RESUMEN Los hemangiomas del seno cavernoso son considerados como malformaciones vasculares o tumores vasculares, se desarrollan extraaxiales, pero son histológicamente distintos a la malformación cavernomatosa cerebral. Su clínica puede ser cefalea, alteraciones visuales o paresia de pares craneales. Los métodos diagnósticos son la tomografía, pero principalmente la resonancia contrastada. El tratamiento puede ser mediante microcirugía o radioterapia. Se presenta el caso de un varón de 30 años, sin antecedentes, con 3 años de evolución de cefalea, y 7 meses de diplopía por paresia del VI par craneal. La resonancia contrastada evidencia un proceso expansivo en el seno cavernoso derecho, bordes regulares, hipointensa en T1, hipercaptador de contraste, hiperintensa en T2 y FLAIR, que no restringe en difusión. Se le realizó una craneotomía más resección total de la tumoración con apoyo de matriz hemostática para el control del sangrado. En el posoperatorio presento oftalmoparesia completa que fue mejorando en el tiempo. Se concluye que el hemangioma del seno cavernoso es una patología rara, con alta morbimortalidad asociada, pero con una adecuada técnica quirúrgica se pueden obtener buenos resultados.

ABSTRACT Cavernous sinus hemangioma is considered as a vascular malformation or as a vascular tumor. It is usually extra-axially located, but it is histologically different from cavernomatous cerebral malformations. Clinical features may include headache, visual alterations or cranial nerve palsy. Diagnostic methods include CT scans, but the best is contrast-enhanced magnetic resonance imaging (MRI). Therapy may be microsurgery or radiotherapy. We present the case of a 30-year-old male, with no relevant past history, who had suffered with headache for three years, and diplopia for the last seven months, due to paresis affecting the sixth cranial nerve. Contrast-enhanced MRI showed an expansive lesion in the right cavernous sinus, with regular borders, T1 hypointense, with significant contrast uptake, T2 and FLAIR hyperintense, with no diffusion restriction. A craniotomy plus total resection of the tumor with hemostatic matrix support for controlling bleeding was performed. This patient developed complete ophthalmoparesis that improved over time. It was concluded that cavernous sinus hemangioma is an unusual condition, with high associated morbidity and mortality rates, but good results may be achieved with an adequate surgical technique.

ABSTRACT

Resumen El síndrome de Gradenigo es una entidad infrecuente en la actualidad, con menos de 50 casos reportados en pediatría en los últimos 50 años. Consiste en la tríada de otitis media aguda, parálisis del nervio abducens y dolor en el trayecto del nervio oftálmico del trigémino. Su manejo es controversial ya que por su baja incidencia no hay estudios con un adecuado nivel de evidencia científica que respalden un tratamiento específico. Aunque tradicionalmente el manejo era quirúrgico, la tendencia actual es al tratamiento conservador con antibiótico endovenoso, el cual debe iniciarse de forma oportuna para lograr una adecuada respuesta y evitar los riesgos de los abordajes quirúrgicos. Se presenta el caso de un paciente de 7 años con otitis media aguda complicada con un síndrome de Gradenigo que respondió favorablemente al tratamiento médico conservador con antibiótico endovenoso (ceftriaxona y vancomicina), respaldando con este caso la tendencia actual de manejo.

Abstract Gradenigo's syndrome is a rare entity in the modern era with less than 50 cases reported in the pediatric population in the last 50 years. The clinical triad consists of acute otitis media, abducens nerve palsy and pain in the ophthalmic division of the trigeminal nerve. Treatment is controversial since there are no high quality studies that support an specific management. Although traditionally the management was surgical, the current trends in case reports implies a conservative treatment with early antibiotics that may avoid the risks of a surgical procedure. We present the case of a 7-year-old patient with an acute otitis media complicated with a Gradenigo's syndrome that was successfully managed with endovenous antibiotics (ceftriaxone and vancomycin), supporting with this case the current trends of treatment.

ABSTRACT

We report two adult cases of abducens nerve palsy presenting immediately (within weeks) after they received the first dose of Covishield vaccination. Magnetic resonance imaging (MRI) of the brain obtained after the onset of diplopia demonstrated demyelinating changes. The patients had associated systemic symptoms. Post-vaccination demyelination typically known as acute disseminated encephalomyelitis (ADEM) associated with several vaccines is more common in children. Although the mechanism of the nerve palsy remains unclear, it is suspected to be related to the post-vaccine neuroinflammatory syndrome. Cranial nerve palsies and ADEM-like presentations may represent part of the neurologic spectrum following COVID-vaccination in adults, and ophthalmologists should be aware of these sequelae. Although cases of sixth nerve palsy following COVID vaccination are already reported, associated MRI changes have not been reported from India.

ABSTRACT

El síndrome de Moebius es una enfermedad congénita poco común que se caracteriza por el compromiso unilateral o bilateral del VI y VII par craneal, lo que compromete los músculos que controlan la oculomotricidad, produciendo una parálisis en la abducción del globo ocular y los músculos involucrados en la expresión facial. Su presentación clínica y grados de severidad son variables, puede presentar compromiso simétrico o asimétrico. Adicionalmente, gran parte de los casos se relacionan con trastornos del lenguaje, anomalías musculoesqueléticas y orofaciales. En el presente artículo se presenta el caso de una paciente femenina de 3 años producto de un embarazo trigemelar con diagnóstico clínico de síndrome de Moebius al nacer, confirmado por neuroimagen en la que se evidencia la ausencia bilateral del nervio facial en ángulos pontocerebelosos, adicionalmente con un defecto completo en los movimientos oculares de abducción y aducción lo que impide el estrabismo convergente común en estos pacientes.

Moebius syndrome is a rare congenital disease characterized by unilateral or bilateral involvement of the VI and VII cranial nerves, which compromises the muscles that control ocular motricity with paralysis in the abduction of the eyeball and the muscles involved in the facial expression. Its clinical presentation and degrees of severity are variable, and it can be symmetric or asymmetric. Additionally, most of the cases are related to language disorders, musculoskeletal and orofacial anomalies. This paper presents the case of a 3-year-old female patient, product of a trigemellar pregnancy with a clinical diagnosis of Moebius syndrome at birth, confirmed by neuroimaging, which shows the bilateral absence of the facial nerve in point-lateral angles. Additionally she has a complete defect in abduction and adduction eye movements, which prevents the common convergent strabismus in these patients.

A síndrome de Moebius é uma doença congênita rara caracterizada pelo envolvimento unilateral ou bilateral dos nervos cranianos VI e VII, que compromete os músculos que controlam a oculomotricidade com paralisia na abdução do globo ocular e dos músculos envolvidos na expressão facial. Sua apresentação clínica e graus de gravidade são variáveis, podendo ser um comprometimento simétrico ou assimétrico. Além disso, a maioria dos casos está relacionada a distúrbios de linguagem, anomalias musculoesqueléticas e orofaciais. Este paper apresenta o caso de uma paciente de 3 anos de idade, fruto de uma gravidez trigêmea com diagnóstico clínico de Síndrome de Moebius ao nascimento, confirmado por neuroimagem em que é evidente a ausência bilateral do nervo facial nos ângulos ponto-cerebelares. Além disso, ela tem um defeito completo nos movimentos oculares de abdução e adução, o que impede o estrabismo convergente comum nesses pacientes.

ABSTRACT

We report the case of a 34-year-old female patient, without relevant medical records, with a single pregnancy of 36 + 5 weeks, who suddenly presented diplopia and pain in the right eye of 4 days' evolution. During the evaluation in the Emergency Department, hypertension 144/93 mmHg was evidenced. No other neurological symptoms were found. The neurologist confirms a right abducens nerve palsy, with the rest of the neurological examination being normal. She was admitted to the Critical Patient Unit for imaging studies and hemodynamic monitoring. Magnetic Resonance Imaging (MRI) of the brain was normal. Laboratory tests showed proteinuria in preeclampsia range, so it was decided to interrupt the pregnancy at 37 weeks by cesarean delivery due to lack of obstetrical conditions. During surgery, spinal anesthesia was provided with standard technique, a cerebrospinal fluid (CSF) sample was taken for cytochemical and microbiological studies, which were subsequently reported as normal. No significant hemodynamic alterations were presented during surgery, concluding without incidents. After 48 hours of delivery the NC VI palsy resolves completely. Similar cases have been reported by other authors, highlighting isolated cranial nerve palsy as a unique presentation, without other neurological involvement, a very rare presentation of preeclampsia. The most likely etiology is the compromise of the vessels of the affected nerve, and it is essential to study with a MRI and rule out autoimmune, endocrinologic, neurologic and any infectious disease of the CNS. The approach must be multidisciplinar to decide the risk/benefit of continuing pregnancy. Resolution is spontaneous and during puerperium. It is recommended to manage in the Critical Patient Unit with both neurological and ophthalmologic follow-up during the pre and post delivery period.

Presentamos el caso de una paciente femenina de 34 años, sin antecedentes médicos relevantes, cursando embarazo único de 36 + 5 semanas de gestación, quien comienza de forma aguda con diplopía y dolor en ojo derecho de 4 días de evolución. Durante la evaluación en el Servicio de Urgencias se objetiva hipertensión 144/93 mmHg. No se refieren otros síntomas neurológicos. Neurólogo constata una parálisis del nervio abducens (NC VI) derecho, con resto de examen neurológico normal. Se decide su ingreso a la unidad de paciente critico para estudio imagenológico y vigilancia hemodinámica. RNM de encéfalo normal. Al laboratorio destaca proteinuria en rango de preclampsia por lo que se decide interrumpir el embarazo a las 37 semanas mediante cesarea a falta de condiciones obstetricas. Durante la resolución se realiza anestesia espinal con técnica habitual, y se toma muestra de LCR para estudio citoquímico y microbiológico, posteriormente, informado como normal. No se presentaron alteraciones hemodinamicas significativas durante el intraoperatorio, concluyendo sin incidentes. Luego de 48 h del parto la parálisis del NC VI se resuelve completamente. Casos similares han sido reportados por otros autores, destacando la parálisis aislada de un nervio creneal como presentacion única, sin otra afectación neurológica, una muy rara presentación de preeclampsia. Su etiologia más probable es el compromiso de la vasculatura del nervio afectado y es fundamental realizar un estudio con neuroimágen (RNM) y descartar enfermedad propia del SNC infecciosa, sistemica autoinmune u otro tipo de enfermedad endocrinológica. El enfrentamiento es miltidisciplinario para decidir el riesgo/beneficio de continuar con el embarazo. La resolución es espontánea y durante el puerperio, se recomienda su manejo en Unidad de Paciente Crítico junto a seguimiento neurológico y evaluación oftalmológica durante el pre y posoperatorio.

ABSTRACT

ABSTRACT We report the case of a previously healthy 48-year-old man who developed an isolated abducens nerve palsy 18 days after presenting with coronavirus disease (COVID-19) confirmed by reverse transcriptase polymerase chain reaction. His main complaint at arrival was double vision. Ocular examination revealed a sixth cranial nerve palsy in the left eye. The incomitant esotropia at arrival was 30 prism diopters. Abduction was markedly limited, while adduction was normal in the left eye. The patient underwent complete clinical, neurological, and neuroimaging investigations, including cerebrospinal fluid sample analysis to rule out infectious causes. A conservative approach with orthoptic therapy and Fresnel prism was opted. Eight months after the onset of COVID-19, regression of the strabismus was observed, and the patient reported complete recovery of the diplopia. This case suggests that isolated abducens nerve palsy caused by severe acute respiratory syndrome coronavirus 2 infection may improve with a conservative approach.

RESUMO Reportamos o caso de homem previamente hígido, 48 anos, com paralisia isolada do nervo abducente 18 dias após infecção pelo novo coronavírus (COVID-19) confirmada por reação cadeia polimerase de transcriptase reversa. A principal queixa do paciente na admissão era diplopia. O exame ocular revelou paralisia do sexto nervo craniano do olho esquerdo. Esotropia incomitante no exame inicial media 30 dioptrias prismáticas. Abdução estava limitada com adução completa no olho esquerdo. O paciente foi submetido a investigação clínica e neurológica com exame de neuroimagem, incluindo análise de amostra do líquido cefalorraquidiano para descartar causas infecciosas. Optou-se por abordagem conservadora com terapia ortóptica e prisma de Fresnel. Oito meses após a infecção pelo COVID-19, o paciente evoluiu com regressão do estrabismo e informou recuperação completa do quadro. Este relato sugere que paralisia isolada do nervo abducente causada por SARS-CoV-2 pode melhorar com abordagem conservadora.

ABSTRACT

Papilledema is defined as optic disc swelling that is secondary to elevated intracranial pressure. Vision is usually well preserved with this condition. The optic discs appear blurred in papilledema. Elevation in intracranial pressure is due to variety of reasons of which intracranial hemorrhageis the most common. We present a case in which our patient developed papilledema due to vitamin B12 deficiency. Lateral rectus muscle palsy occurs due to abducens nerve palsy. The lateral rectus muscle is responsible for lateral movement of the eyeball, specificallyabduction. Its palsy results in sudden onset of horizontal double vision, which is worse when the patient looks to the affected side. There is also limited outward movement of the affected eye. Abducens nerve palsy can occur due to ischemia injury, stroke, infection, brain tumour, elevated intracranial pressure, or inflammation of the nerve. In our patient the abducens nerve palsy was due to homocysteinemia secondary to dietary vitamin B12 deficiency. Homocysteine is a potent atherosclerotic risk factor and can cause ischemic nerve palsy, as seen in our patient.

ABSTRACT

The authors describe a rare case of abducens nerve schwannoma, manifested with headache and diplopia, associated to right side cerebellar syndrome. During surgery, the authors identified that the origin of the tumor was from the abducens nerve, and the histopathological diagnosis confirmed that it was a schwannoma. A gross total tumor resection was performed, and the patient recovered from her symptoms 1 month after surgery. The authors followed the Case Report guidelines (CARE) guideline and the patient authorized the authors to publish the present case report by signing an informed consent form.

Os autores descrevem um raro caso de Schwannoma do nervo abducente, cuja manifestaçao clínica foi com cefaleia e diplopia, associadas à síndrome cerebelar hemisférica direita. Durante a cirurgia, os autores identificaram que o tumor tinha sua origem junto ao nervo abducente, e o diagnóstico histopatológico confirmou schwannoma. Realizou-se uma ressecção completa do tumor e o paciente apresentou melhora total dos sintomas em um mês após a cirurgia. Os autores seguiram as diretrizes do CARE para produzir este relato e o paciente assinou o termo de consentimento livre e esclarecido, autorizando a publicação deste caso.

ABSTRACT

Reporte de caso de síndrome de pseudo-Duane asociado a schwannoma de nervio abducens y neurofibromatosis tipo 2 (NF2). Este síndrome es raro, caracterizado por limitación en abducción, retracción ocular, disminución de hendidura palpebral en abducción y restricción del recto medial ipsilateral en test de ducción forzada. La NF2 es también una enfermedad infrecuente caracterizada por tumores de sistema nervioso central y periférico. Los schwannomas de nervio abducens son también poco frecuentes, y se presentan comúnmente con diplopia. Se revisan brevemente estas enfermedades. Es el primer caso reportado de pseudo-Duane secundario a schwannoma de nervio abducens y NF2 según nuestro conocimiento.

A pseudo-Duane syndrome case associated with abducens nerve schwannoma and neurofibromatosis type 2 (NF2) is presented. This syndrome is a rare disease characterised by abduction limitation, ocular retraction, narrowing of the palpebral fissure in abduction, and ipsilateral medial rectus restriction on forced duction test. NF2 is also an uncommon disease which is characterised by peripheral and central nervous system tumours. Abducens nerve schwannomas are also uncommon and presents usually as diplopia. A short review of these diseases is given. This is the first case of pseudo-Duane secondary to abducens nerve schwannoma, to our knowledge.

ABSTRACT

Introducción: El abordaje del espacio subaracnoideo fue descrito por Quincke en el 1891. En la actualidad es práctica común para la realización de la anestesia neuroaxial subaracnoidea en las pacientes obstétricas. Las complicaciones descritas, asociadas a esto, son varias. Dentro de estas, la parálisis del nervio abducens o VI par no es frecuente y en ocasiones, no está relacionada a la punción ya que se produce días después del evento. Objetivo: Revisar la información relacionada con la complicación de parálisis del VI par. Presentación del caso: Paciente de 33 años de edad, femenina, de profesión médico, con antecedentes personales de migraña, historia de anestesia neuroaxial epidural sin complicaciones, que para la realización de una cesárea de segmento arciforme y salpinguectomia parcial bilateral, recibió una anestesia combinada peridural-espinal. El transoperatorio transcurre con estabilidad hemodinámica, hizo cefalea al tercer día del posoperatorio, que la atribuyó al antecedente de migraña y fue tratada sin evaluación por anestesiología con dipirona. A los 10 días de operada hace desviación de la mirada y diplopia, se diagnostica parálisis del VI par. Fue tratada por Neurología y se plantean varios diagnósticos diferenciales. Los estudios imagenológicos resultan negativos, se trató con vitaminas y se produjo remisión a las 6 semanas. Conclusiones: El diagnóstico de esta complicación es necesario ya que puede pasar inadvertida la relación con la anestesia y, por tanto, ser mal conducido su tratamiento(AU)

Introduction: The approach to the subarachnoid space was described by Quincke in 1891. It is now a common practice to perform subarachnoid neuroaxial anesthesia in obstetric patients. The complications described, associated with this, are several. Within these, the paralysis of the abducens nerve or sixth pair is not frequent and sometimes is not related to the puncture, since it occurs days after the event. Objective: To review the information related to the complication of paralysis of the sixth pair. Case presentation: A 33-year-old female patient, a physician, with a personal history of migraine, a history of epidural neuroaxial anesthesia without complications, who underwent combined epidural-spinal anesthesia for performing a cranial segment cesarean section and bilateral partial salpingectomy. The transoperative period runs with hemodynamic stability. There was headache three days after surgery, which was attributed to the migraine history and the patient was treated, without evaluation by anesthesiology, with dipyrone. At 10 days after surgery, the eyes are diverted and diplopia is manifested, paralysis of the sixth pair is diagnosed. She was treated by neurology and several differential diagnoses were proposed. Imaging studies are negative. She was treated with vitamins and remission occurred at six weeks. Conclusions: The diagnosis of this complication is necessary, since the relationship with anesthesia may go unnoticed and, therefore, its treatment may be poorly conducted(AU)

ABSTRACT

Chronic subdural hematoma (CSDH) is a form of progressive intracranial hemorrhage, typically associated with cases of trauma. The manifestation of this comorbidity with abducens palsy is a rare finding. The present work aims to describe the case of an adult patient with abducens nerve palsy as a manifestation of CSDH. Chronic subdural hematoma is most commonly found in elderly patients, with systemic hypertension as amanifestation. The relation with the sixth cranial nerve is unusual and draws attention to the case reported. In addition, the prognosis is positive, since trepanation and drainage surgery was performed, as it is recommended in the literature.

ABSTRACT

Of all the cranial nerves, the abducens nerve has the longest intracranial course hence is most common cranial nerve to be affected secondary to any potentially devastating intracranial cause. It can indicate significant underlying pathology. Abducens or sixth cranial nerve innervates lateral rectus muscle and pathology of this nerve results in abduction deficiency of ipsilateral eye. Most of the time it will be unilateral but bilateral involvement is also well known. It can recurrent without any underlying identifiable pathology. The 6th nerve palsy is considered as benign after ruling out all possible causes. Benign causes account for just 9 to 14% of all 6th nerve palsies in children. Most of the time benign 6th nerve palsy occurs after viral infection or vaccination as an immunological reaction. In our case patient had history of pentavalent vaccination 1 month back. After thorough investigation and ruling out all possible causes it was attributed to post vaccination immunological reaction. which resolved spontaneously over 4months.

ABSTRACT

Resumo A síndrome de Pierre Robin (PRS) consiste em uma tríade de anomalias caracterizada por micrognatia, glossoptose e fissura de palato, comumente associada com outras síndromes e ocasionalmente com alterações oculares. Na Síndrome de Duane (DRS), há uma falha na inervação do reto lateral pelo VI nervo, com inervação anômala do reto lateral por fibras do III nervo. Ainda que a PRS já tenha sido associada com mais de 50 outras síndromes, não existe na literatura relato de casos de associação com a DRS familiar. Dessa forma, esse trabalho tem por objetivo relatar um caso dessa associação em um paciente de 29 anos com recorrência das síndromes na família.

Abstract The Pierre Robin Syndrome (PRS) consists of a triad of anomalies characterized by micrognathia, glossoptosis and fissure of the palate, usually associated with other syndromes e occasionally associated with ocular variations. In Duane Retraction Syndrome (DRS), there is a failure in the lateral rectus innervation by the VI cranial nerve, with anomalous innervation of the lateral rectus by fibers of the III nerve. Even though PRS has already been associated with more than 50 other syndromes, there is not any report in literature of association with familial DRS. Thus, this work aims to report a case of this association in a 29 years old patient with recurrence of the syndromes in the family.

ABSTRACT

Ossification of parts of the intracranial dura mater is common and is generally accepted as an age-related finding. Additionally, duplication of the abducens nerve along its course to the lateral rectus muscle is a known, although uncommon anatomical variant. During routine cadaveric dissection, an ossified portion of dura mater traveling over the trigeminal nerve's entrance (porus trigeminus) into the middle cranial fossa was observed unilaterally. Ipsilaterally, a duplicated abducens nerve was also observed, with a unique foramen superolateral to the entrance of Dorello's canal. To our knowledge, there has been no existing report of a simultaneous ossified roof of the porus trigeminus with an ipsilateral duplicated abducens nerve. Herein, we discuss this case and the potential clinical and surgical applications. We believe this case report will be informative for the skull base surgeon in the diagnosis of neuralgic pain in the frontomaxillary, andibular, orbital, and external and middle ear regions.

ABSTRACT

PURPOSE: We report a patient with delayed-onset abducens nerve palsy and Horner syndrome after endovascular treatment of traumatic carotid-cavernous fistula (CCF). CASE SUMMARY: A 68-year-female visited our ophthalmic department complaining of gradual-onset ptosis of the left eye and horizontal diplopia. She had undergone endovascular treatment to treat left-sided traumatic CCF after a car accident 10 years before; she had been told at that time that the treatment outcome was favorable. The left-sided ptosis gradually developed 6 years after the procedure, accompanied by diplopia. The left eye exhibited miosis and the extent of anisocoria increased in dim light. An extraocular examination revealed 30 prism diopters of left esotropia in the primary gaze and a −4 abduction limitation of the left eye. CCF recurrence was suspected; however, magnetic resonance imaging with magnetic resonance angiography of brain did not support this. The esotropia did not improve during the 6-month follow-up and strabismus surgery was performed. CONCLUSIONS: Delayed-onset abducens nerve palsy and Horner syndrome can develop even after successful endovascular treatment of CCF. Strabismus surgery should be considered in patients whose diplopia does not spontaneously improve.

ABSTRACT

The sixth abducens nerve is subject to injury after rare complications of intracranial hypotension caused by procedures such as dural punctures and spinal surgeries. The purpose of this case report is to discuss the mechanism of nerve palsy in these situations. Therefore, we describe a case of onset of contralateral sixth cranial nerve palsy after intracranial aneurysm and temporal meningioma surgery. Moreover, in this case there is a singularity due to the presence of the petroclival meningioma that amplified the unfolding of the lesion.

O sexto nervo abducente está sujeito a lesões após raros eventos de hipotensão intracraniana gerada por procedimentos como punções de dura-máter e cirurgias de coluna. O propósito deste relato de caso é discutir o mecanismo da paralisia deste nervo nestas situações. Para isso, descrevemos um caso de aparecimento de paresia do sexto nervo craniano contralateral após cirurgia de aneurisma intracraniano e de meningioma temporal. Além do mais, neste caso há uma singularidade em razão da presença do meningioma petroclival contralateral, que amplificou o desdobramento da lesão.

ABSTRACT

Objective To observe the clinical efficacy of acupuncture plus medication in treating diabetic abducens nerve palsy.Method Twenty-three cases of diabetic abducens nerve palsy were randomized into a treatment group of 12 cases and a control group of 11 cases. The two groups both were intervened by Compound anisodine hydrobromide via para-temporal-superficial-artery injection, based on which, the treatment group received acupuncture at extraocular muscles and body acupoints, while the control group received subconjunctival injection of Dexamethasone beside the endpoint of rectus lateralis. The fasting blood glucose, eye movement and diplopia were observed before and after the intervention for the two groups to evaluate the therapeutic efficacy.Result After the intervention, the two groups didn't show significant intra-group or inter-group differences in fasting blood glucose (P>0.05). The total effective rate was 91.7％ in the treatment group versus 54.5％ in the control group, and the between-group difference was statistically significant (P<0.05).Conclusion Acupuncture plus medication is an effective method in treating diabetic abducens nerve palsy.

ABSTRACT

Sudden headache onset may rarely be caused by spontaneous intracranial hypotension (SIH). Other associated symptoms in patients with SIH are nausea, vomiting, vertigo, hearing alteration, and visual disturbance. This case report describes a 43-year-old female diagnosed with SIH who developed diplopia after resolution of an abrupt-onset headache, which was managed with conservative treatments, including bed rest and hydration. She was also diagnosed with secondary right sixth cranial nerve palsy. Although conservative management relieved her headache, the diplopia was not fully relieved. Application of an autologous epidural blood patch successfully relieved her diplopia, even after 14 days from the onset of visual impairment.

ABSTRACT

@#Ramsay Hunt syndrome, associated with varicella zoster virus infection is characterized by herpes zoster oticus, facial nerve palsy, and cochleovestibular symptoms. Ramsay Hunt syndrome associated cranial polyneuropathy occasionally occurs with involvement beyond VII and VIII. We represent a patient of Ramsay Hunt syndrome who presented with only VI involvement at the first visit followed by cranial polyneuropathy. Varicella zoster virus infection was confirmed by the detection of varicella zoster virus-DNA in cerebrospinal fluid.

ABSTRACT

PURPOSE: To report a case of isolated abducens nerve palsy caused by the ophthalmic segment of an internal carotid artery (ICA) aneurysm which improved after endovascular coil trapping. CASE SUMMARY: A 59-year-old female visited the ophthalmology department for a sudden onset of horizontal diplopia for 10 days. The best corrected visual acuity was 20/20 in both eyes. The pupils showed normal response to light and near stimulation in both eyes. The extraocular examination showed 35 prism diopters left esotropia at primary gaze and −4 abduction limitation of the left eye. The patient suffered intermittent headaches in the left temporal area and left retrobulbar pain for 1 month. Magnetic resonance imaging with magnetic resonance angiography of the brain was performed. A focal protruding lesion of the left ICA suggested an aneurysm. The patient consulted with the neurosurgery department. The left ophthalmic segment of the ICA aneurysm was confirmed by transfemoral cerebral angiography and treated with coil placement and the patient showed gradual improvement after the procedure. Three months after the procedure there was no diplopia. The patient showed orthotropia at primary gaze without abduction limitation. CONCLUSIONS: Isolated abducens nerve palsy can be caused by the ophthalmic segment of an ICA aneurysm, which should be considered in the differential diagnosis of ocular motility disorders. The disorder improved with coil replacement treatment. Differential diagnosis as a cause of abducens nerve palsy is important for prompt and appropriate treatment. Neuroimaging should be considered in patients with isolated abducens nerve palsy with a non-ischemic origin.