Acute abducens nerve palsy with acute disseminated encephalomyelitis-like presentation following COVID-19 vaccination

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.

Abducens Nerve Palsy as Initial Manifestation of Chronic Subdural Hematoma: Case Report

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.

Palsy of the Contralateral Abducens Nerve after Aneurysm Surgery and Temporal Meningioma in the Presence of Petroclival Meningioma: A Case Report

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.

Epidural blood patch treatment of diplopia that developed after headache resolution in a patient with spontaneous intracranial hypotension

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.

Abducens Nerve Palsy Associated with Ramsay-Hunt Syndrome / 대한평형의학회지

Ramsay-Hunt syndrome is an infectious disease caused by the varicella zoster virus. It is usually associated with facial and vestibulocochlear nerve palsy, but other cranial nerve dysfunction can be accompanied. We present a 68-year-old woman with abducens nerve palsy associated with Ramsay-Hunt syndrome. She showed abduction limitation of left eye with peripheral facial palsy and vestibulopathy of the left side. Varicella zoster virus polymerase chain reaction of cerebrospinal fluid was positive and internal auditory canal magnetic resonance imaging was revealed enhancement of labyrinthine segment of left facial nerve. Although abducens nerve palsy is uncommon feature of Ramsay-Hunt syndrome, but it can be developed by several different mechanisms.

Abducens Nerve Palsy and Optic Perineuritis Caused by Fungal Sphenoidal Sinusitis

PURPOSE: To report a case of abducens nerve palsy and optic perineuritis caused by fungal sphenoidal sinusitis. CASE SUMMARY: A 48-year-old male visited emergency department for retrobulbar pain, decreased vision, and horizontal diplopia for 3 days. He reported that previous medical history was non-specific, however, blood glucose level was 328 mg/dL (70–110). He had experienced severe headache for 7 days. The best corrected visual acuity was 20/20 at right eye and 20/25 at left eye. The pupil of left eye did not have relative afferent pupillary defect. Left mild proptosis was noted. The extraocular examination showed 30 prism diopters left esotropia at primary gaze and −4 abduction limitation of left eye. The left eye showed mild optic disc swelling and inferior field defect by field test. Brain magnetic resonance imaging showed enhancement of sphenoidal sinus, ethmoidal sinus, and around optic nerve at left eye. Three days after antibiotics treatment, the vision of left eye deteriorated to 20/40 and periorbital pain developed. The drainage and biopsy of sphenoidal sinus were performed. The histopathologic examination showed hyphae consistent with aspergillosis. The ocular symptoms were improved with anti-fungal treatment. Follow-up magnetic resonance imaging performed 1 month after treatment showed improvement of lesion at left orbit. Five months after surgery, the visual acuity of left eye was improved to 20/25. The patient showed orthotropia at primary gaze without limitation. CONCLUSIONS: The abducens nerve palsy and optic perineuritis can be caused by fungal sphenoidal sinusitis. The early diagnosis and appropriate treatment can lead to favorable outcome.

Abducens Nerve Palsy Caused by the Ophthalmic Segment of an Internal Carotid Artery Aneurysm

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.

Ramsay Hunt syndrome presenting with abducens nerve palsy followed by V, VII, VIII, IX, and X nerve palsies

@#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.

A Case of Idiopathic Unilateral Abducens Nerve Palsy in an Adolescent Patient

PURPOSE: To report a case of idiopathic unilateral abducens nerve palsy in an adolescent patient. CASE SUMMARY: A healthy 14-year-old boy presented with binocular horizontal diplopia that started that same day. He did not have any history of trauma, vaccination or infectious disease and showed no other neurological signs. The best corrected visual acuity of both eyes was 20/20. Slit lamp and fundus examinations revealed no other abnormalities. On the alternative prism cover test, he had 6 prism diopter (PD) esotropia with −1 degree abduction limitation in the left eye. After 1 week, the abduction limitation in the left eye was progressed to −3.5 degrees, so we performed brain imaging. The brain magnetic resonance imaging (MRI) and systemic evaluation (serologic test, cerebrospinal fluid examination) were normal therefore, we suspected idiopathic unilateral abducens nerve palsy. Thus, intravenous steroid injection was started, and the patient was partially recovered after 5 days of treatment. At 5 weeks after presentation, diplopia and abduction limitation in the left eye were completely resolved, and recurrence was not found during the 1 year of follow-up. CONCLUSIONS: We report a case of progressive idiopathic unilateral abducens nerve palsy in an adolescent which has resolved completely after intravenous steroid treatment in a short period.

Diffuse Neonatal Hemangiomatosis with Unilateral Cranial Nerve Palsy Improved by Propranolol

Diffuse neonatal hemangiomatosis (DNH) is characterized by multiple capillary or cavernous hemangiomas on the skin and internal organs occurring during the neonatal period. It is a life-threatening condition due to high-output heart failure with a mortality rate of 60-85% without proper treatment. The areas that are most commonly involved include the skin (100%), liver (64-100%), and central nervous system (52%). Corticosteroids are the drugs of choice as an initial treatment and have a response rate of 30-60%. We present here a case of a newborn baby with multiple hemangiomas on her skin (scalp, lips, neck, back, shoulder, arm, buttock, and leg), brain (right cerebellum, pons, and medulla oblongata), lungs, liver, kidney, and bones. She suffered from 6th, 7th, 9th, 10th, and 12th cranial nerve palsy resulting from hemorrhage of the hemangiomas in the brain. The first-line treatment of prednisolone (4 mg/kg/day) was not effective and propranolol (2 mg/kg/day) was administered as a second-line treatment. After 2 weeks of treatment, the hemangiomas had decreased in size with no associated acute hemorrhage. The infant is now 10 months old and both the multiple hemangiomas and cranial nerve palsy have improved. Propranolol was effective without significant adverse effects in treating DNH resistant to corticosteroids.

Acute Rhinosinusitis in Prominently Pneumatized Sphenoid Sinus Presenting with Unilateral Abducens Nerve Palsy / 대한이비인후과학회지

Acute rhinosinusitis is a rare cause of abducens nerve palsy. Most reported cases with VIth cranial nerve palsy associated sphenoid sinusitis are fungal sphenoid sinusitis, mucocele, or severe bacterial sinusitis. In this report, we present a patient with acute mild sphenoid sinusitis presented as abducens nerve palsy associated with prominent sphenoid pneumatization to the Dorello's canal.

Petrositis With Bilateral Abducens Nerve Palsies complicated by Acute Otitis Media

Petrous apicitis is a rare but fatal complication of otitis media. An infection within the middle ear can extend within the temporal bone into the air cells of the petrous apex. With only the thin dura mater separating the trigeminal ganglion and the 6th cranial nerve from the bony petrous apex, they are vulnerable to inflammatory processes, resulting in deep facial pain, lateral rectus muscle paralysis, and diplopia. In 1904, Gradenigo described a triad of symptoms related to petrous apicitis, including acute suppurative otitis media, deep facial pain resulting from trigeminal involvement, and abducens nerve palsy. It has traditionally been treated with surgery, but recent advances in imaging, with improved antibiotic treatment, allow conservative management. In this case report, we describe a clinical and neuroradiological evolution of a child with a petrous apicitis after acute otitis media, which was managed medically with a positive outcome.

Isolated abducens nerve palsy with hyperhomocysteinemia: Association and outcomes.

hypertension, dyslipidemia, carotid artery disease, etc., In this report, we describe four patients with isolated abducens nerve palsy who presented with an acute onset diplopia whose detailed history and examination were suggestive of an ischemic etiology. Detailed systemic and laboratory evaluation revealed hyperhomocysteinemia as the only potential risk factor. To the best of our knowledge this is the first report of association of hyperhomocysteinemia and isolated abducens nerve palsy.

A Case of Abducens Nerve Palsy after Percutaneous Nerve Block for Trigeminal Neuralgia

PURPOSE: To report a case of abducens nerve palsy after a percutaneous nerve blocking procedure for trigeminal neuralgia. CASE SUMMARY: A 35-year-old female complaining of stabbing pain in the right maxillary area 4 months in duration was diagnosed with trigeminal neuralgia at a pain clinic. The patient underwent a percutaneous trigeminal nerve blocking procedure using alcohol at the right maxillary nerve. After the procedure, the patient was referred to an ophthalmologic service for horizontal diplopia and abduction defect of her right eye. Her corrected visual acuity, intraocular pressure, pupillary response, anterior segment and fundus were normal bilaterally. The patient had right esotropia of 38 prism diopters in primary gaze (70 prism diopters in right gaze, 20 prism diopters in left gaze) with limited abduction of -3 in the right eye. She was diagnosed with abducens nerve palsy of the right eye. Three months after initial presentation, the patient had intermittent esotropia of 4 prism diopters at right gaze and orthophoria at the other diagnostic gazes; she presented no diplopia. CONCLUSIONS: In the present case study, abducens nerve palsy following a percutaneous trigeminal nerve blocking procedure resolved over 3 months. Because the abducens nerve is adjacent to the trigeminal nerve near the foramen ovale based on anatomical structure, when performing a percutaneous trigeminal blocking procedure, the surgeon should be aware that deep needle puncture could cause abducens nerve palsy.

Slowly Recovering Isolated Bilateral Abducens Nerve Palsy after Embolization of Ruptured Anterior Communicating Artery Aneurysm

Bilateral abducens nerve palsy related to ruptured aneurysm of the anterior communicating artery (ACoA) has only been reported in four patients. Three cases were treated by surgical clipping. No report has described the clinical course of the isolated bilateral abducens nerve palsy following ruptured ACoA aneurysm obliterated with coil. A 32-year-old man was transferred to our institution after three days of diplopia, dizziness and headache after the onset of a 5-minute generalized tonic-clonic seizure. Computed tomographic angiography revealed an aneurysm of the ACoA. Magnetic resonance imaging showed focal intraventricular hemorrhage without brain stem abnormalities including infarction or space-occupying lesion. Endovascular coil embolization was conducted to obliterate an aneurysmal sac followed by lumbar cerebrospinal fluid (CSF) drainage. Bilateral paresis of abducens nerve completely recovered 9 weeks after ictus. In conclusion, isolated bilateral abducens nerve palsy associated with ruptured ACoA aneurysm may be resolved successfully by coil embolization and lumbar CSF drainage without directly relieving cerebrospinal fluid pressure by opening Lillequist's membrane and prepontine cistern.

Horner's Syndrome and Contralateral Abducens Nerve Palsy Associated with Zoster Meningitis

A 55-year-old woman presented with diplopia following painful skin eruptions on the right upper extremity. On presentation, she was found to have 35 prism diopters of esotropia and an abduction limitation in the left eye. Two weeks later, she developed blepharoptosis and anisocoria with a smaller pupil in the right eye, which increased in the darkness. Cerebrospinal fluid analysis showed pleocytosis and a positive result for immunoglobulin G antibody to varicella zoster virus. She was diagnosed to have zoster meningitis with Horner's syndrome and contralateral abducens nerve palsy. After intravenous antiviral and steroid treatments, the vesicular eruptions and abducens nerve palsy improved. Horner's syndrome and diplopia resolved after six months. Here we present the first report of Horner's syndrome and contralateral abducens nerve palsy associated with zoster meningitis.

Bilateral Abducens Nerve Palsy in Pediatric Patients with Epstein-Barr Virus Encephalitis

PURPOSE: To report 2 cases that presented with bilateral abducens nerve palsy associated with Epstein-Barr virus (EBV) encephalitis in children. CASE SUMMARY: Case 1. A 14-month-old boy presented with fever and esodeviation of the left eye that started 5 days earlier. On the ophthalmic examination, 45-PD esotropia of the left eye and limitation of abduction in both eyes were observed. On neurological examination, there were no abnormalities. Serologic test and polymerase chain reaction (PCR) from cerebrospinal fluid (CSF) were positive for EBV. The patient was treated with systemic acyclovir and prednisolone. Part-time occlusion therapy of the right eye for 2 hours/day was also prescribed. The patient underwent a 6.5-millimeter recession of the medial rectus and a 6-millimeter resection of the lateral rectus on the left eye 7 months after the presentation. The patient showed orthotropia 1 week after the surgery without neurologic sequelae. Case 2. A 13-year-old boy presented with headaches and fever that started 5 days before and altered consciousness with seizures 2 days previously. Serological test for viral infection was normal, except for EBV, and CSF examination showed viral infection. After the patient recovered consciousness, he complained of diplopia. A 30-PD esotropia of his left eye with bilateral limitation of abduction was present. Alternating full-time occlusion of both eyes was prescribed. At 4 months after presentation, diplopia disappeared and the patient showed orthotropia without abduction limitation; however, anticonvulsants were prescribed to control seizures. CONCLUSIONS: In children, EBV encephalitis can be accompanied by acquired bilateral abducens nerve palsy. Residual nerve palsy and other neurologic sequelae can remain after several months.

Síndrome de Moebius: descripción de una serie de 6 casos / Moebius syndrome: description of a 6 cases series

La parálisis facial y del nervio abducens congénita fue descrita como entidad clínica en 1888. Esta definición se amplió a parálisis facial unilateral o bilateral completa o incompleta, limitación de abducción ocular, disfunción de otros pares craneales, defectos oro-faciales, músculoesqueléticos y del desarrollo. Los criterios de diagnóstico varían y la entidad sigue siendo subdiagnosticada. El objetivo de este trabajo es caracterizar el cuadro clínico de pacientes con diagnóstico de Síndrome de Moebius, a través de la revisión de seis casos en control en dos Policlínicos de Neurología Infantil. En este grupo, fueron motivo de consulta: falta de esfuerzo respiratorio, hipomimiafacial, trastorno de alimentación. En dos casos hubo uso de misoprostrol durante el embarazo. Los hallazgos del examen incluyeron parálisis facial bilateral (5), unilateral (1), alteración bilateral de abducción ocular (6). Otras malformaciones asociadas fueron: paladar alto, microretrognatia, fisurapalatina, criptorquidia, polidactilia bilateral y pie bot. El conocimiento extendido de las características mínimas para el diagnóstico y de la variedad de manifestaciones de el Síndrome de Moebius, facilitan su reconocimiento y tratamiento oportuno.

Congenital facial and abducens nerves palsy were first described as a clinical entity in 1888. Later the definition was expanded to unilateral or bilateral facial palsy, limitation of ocular abduction, other cranial nerves involvement, orofacial, musculoskeletal or developmental defects. Diagnostic criteria vary among authors and the condition remains probably underdiagnosed. The aim of this study is to characterize the clinical features of Moebius Syndrome in a group of six patients diagnosed and controlled at two Child Neurology Outpatients Clinics. In this group, the main complaint at first consultation was: lack of respiratory effort, facial hypomimia, eating disorder. The use of misoprostol during pregnancy was identified in two cases. Findings on physical examination included bilateral (5) and unilateral (1) facial palsy, bilaterally impaired conjugate gaze (6).Other associated findings were: high palate, microretrognathia, cleft palate, polydactyly, bilateral cryptorchidism and clubfoot. The extended knowledge of minimal criteria required for Moebius Syndrome diagnosis, as well as other associated features, will facilitate recognition and timely treatment.

Epidural Blood Patch for the Treatment of Abducens Nerve Palsy due to Spontaneous Intracranial Hypotension: A Case Report

Intracranial hypotension is characterized by a postural headache which is relieved in a supine position and worsened in a sitting or standing position. Although less commonly reported than postural headache, sixth nerve palsy has also been observed in intracranial hypotension. The epidural blood patch (EBP) has been performed for postdural puncture headache, but little is known about the proper timing of EBP in the treatment of sixth nerve palsy due to intracranial hypotension. This article reports a case of sixth nerve palsy due to spontaneous intracranial hypotension which was treated by EBP 10 days after the onset of palsy.

Isolated Bilateral Abducens Nerve Palsy Caused by Basilar Artery Dissecting Aneurysm

Bilateral abducens nerve palsy is mediated mainly by increased intracranial pressure, accompaniment to subarachnoid hemorrhage and others, relatively direct involvement of abducens nerve nucleus or its intracranial pathway is unusual case. A 45-year-old male patient complaining of double vision showed isolated bilateral abducens palsy. Cerebral angiography revealed a dissecting aneurysm of the basilar artery. Bilateral abduction deficit has resolved after stent assisted coil embolization. We suggest that basilar artery dissecting aneurysm should be included as a cause of bilateral abducens nerve palsy.