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.

Paralisia do VI nervo (abducente) / VI nerve palsy (abducens palsy)

Neste trabalho foi realizada uma revisão da literatura com o objetivo de integrar e compilar artigos disponíveis sobre a paralisia do VI nervo (abducente) para rever suas características clínicas, etiologias possíveis e os procedimentos clínicos, farmacológicos e cirúrgicos para seu tratamento. Primeiramente, descreve-se sua ação, localização, trajeto e possíveis lesões, depois seus principais fatores etiológicos para em seguida abordar-se o diagnóstico e o tratamento. Proposta de transposição de Carlson-Jampolsky isolada no tratamento cirúrgico da paralisia do VI nervo é também apresentada.

The authors review the basic aspects, etiology, clinical signs, diagnosis and treatment of the VI nerve palsy. Review the possible causes of abducent paralysis and location of determinant lesions. The clinical signs and clinical follow up are also observed in order to guide the etiology and therapeutic. The authors describe the clinical, pharmacological and surgical treatment. The authors emphasizes their proposal of VI nerve palsy correction using the isolated Carlson-Jampolsky transposition.

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.

Differential Diagnosis of Lemierre's Syndrome in a Patient with Acute Paresis of the Abducens and Oculomotor Nerves

Lemierre's syndrome is characterized by anaerobic septicemia, internal jugular vein thrombosis, and septic emboli associated with infections of the head and neck. We describe an unusual and clinically confusing case of a young woman with an acute paresis of the abducens nerve and partial paresis of the right oculomotor nerve. After an extensive imaging diagnostic procedure, we also documented a peritonsillar abscess and various types of thromboses in intracranial and extracranial veins. Furthermore, we found brain and lung abscesses, which led us to establish the diagnosis of Lemierre's syndrome. Despite intensive anti-coagulation and antibiotic therapy, the patient developed a mycotic aneurysm in the right internal carotid artery directly adjacent to the previously thrombosed cavernous sinus. In summary, we were able to confirm that Lemierre's syndrome may occur in conjunction with uncharacteristic symptoms. Due to the sometimes confusing clinical symptoms as well as clinical and radiological specialties, we had to work on an interdisciplinary basis to minimize the delay prior to establishing the diagnosis and therapy.

Abducens Nerve Palsy Complicated by Inferior Petrosal Sinus Septic Thrombosis Due to Mastoiditis

We present a very rare case of a 29-month-old boy with acute onset right abducens nerve palsy complicated by inferior petrosal sinus septic thrombosis due to mastoiditis without petrous apicitis. Four months after mastoidectomy, the patient fully recovered from an esotropia of 30 prism diopters and an abduction limitation (-4) in his right eye.

Multiple Myeloma Manifesting as a Fluctuating Sixth Nerve Palsy

We report a case of multiple myeloma that presented as a fluctuating sixth cranial nerve palsy in the absence of widespread signs of systemic disease. A 63-year-old woman presented with horizontal diplopia of two weeks duration that subjectively changed over time. Ocular examination showed a fluctuating sixth nerve palsy. A computed tomography (CT) scan of the brain showed multiple, enhancing, soft tissue, mass-like lesions involving the left cavernous sinus and the apex of both petrous bones. Based on bone marrow biopsy and hematologic findings, she was diagnosed with multiple myeloma. Multiple myeloma may be included in the differential diagnosis of a fluctuating sixth nerve palsy, and although ophthalmic signs are rare and generally occur late in the course of multiple myeloma, they can still be its first signs.

Further considerations about the ophthalmic features of the Möbius sequence, with data of 28 cases

PURPOSE: There is no uniformity in the literature about the core features required to make the diagnosis of Möbius sequence. Originally, the minimum requirements were the bilateral paralysis of the VI and the VII cranial nerves. The bilateral facial nerve paralysis or paresis, often asymmetric, is common to all patients but some facts show that the isolated VI nerve palsy in the Möbius sequence is not the rule. 1) When there is an esotropia in Möbius sequence, it is often too small to be caused by a bilateral isolated VI nerve palsy. There are many cases in which there is no esotropia in the primary position and even some cases, though rare, with exotropia. 2) In most cases of Mõbius sequence, the esotropia can be eliminated with a mere recession of the medial rectus muscles. 3) In most patients with Mõbius sequence there is, besides the lateral rectus palsy, a variable degree of adduction limitation, which defines a horizontal gaze palsy. The authors present some arguments to show that the isolated lateral rectus muscle palsy cannot be considered as a sine qua non factor for the diagnosis of Möbius sequence. METHODS: The binocular alignment in primary position and the incidence of abduction and adduction limitations among 28 of the authors' consecutive patients with Möbius sequence and in patients of 5 other randomly selected publications are presented for comments. RESULTS: The eyes' position in primary position among 135 of those 6 authors' patients (28 belonging to the authors of this study and 107 to the other 5) were recorded; 55 of them (40.74 percent) had orthotropia and 9 (6.66 percent) had exotropia. Among 80 patients of 4 authors (22 belonging to the authors of this study and 52 to the other 3), in whom the horizontal versions were analyzed, 79 (98.75 percent) had limitation of abduction and 53 (66.25 percent) had limitation of adduction. COMMENTS: The authors emphasize that the recent studies have shown that inside the VI...

OBJETIVO: Não há uniformidade na literatura sobre as anomalias necessárias para caracterizar a seqüência de Möbius. Originalmente, os requisitos mínimos eram a paralisia do VI e do VII nervos cranianos. A paralisia facial bilateral, às vezes assimétrica, é comum a todos os pacientes, mas alguns fatos mostram que a paralisia isolada do VI nervo não é a regra.1) Quando há esotropia na seqüência de Möbius, é muitas vezes muito pequena para ser causada por paralisia bilateral do VI nervo. Há muitos casos que não apresentam esotropia ou mesmo, embora raramente, têm exotropia. 2) Em muitos casos a esotropia pode ser eliminada com apenas o retrocesso dos retos mediais. 3) Em muitos desses pacientes há, além da limitação de abdução, também limitação de adução, o que define a paralisia conjugada dos movimentos horizontais. Os autores apresentam argumentos para mostrar que a paralisia isolada dos retos laterais não pode ser considerada condição sine qua non para o diagnóstico da seqüência de Möbius. MÉTODOS: O alinhamento binocular em posição primária e a incidência de limitação de abdução e adução entre 28 dos casos consecutivos de seqüência de Möbius dos autores e entre os casos de 5 outros autores eleitos aleatoriamente são apresentados para comentários. RESULTADOS: As posições binoculares em posição primária de 135 pacientes desses 6 autores (28 pertencentes aos autores deste trabalho e 107 dos outros 5) foram anotadas; 55 pacientes (40,74 por cento) tinham ortotropia e 9 (6,66 por cento) tinham exotropia. Entre 80 pacientes de 4 autores (22 pertencentes aos autores e 107 dos outros 3), nos quais as versões horizontais foram estudadas, 79 (98,75 por cento) apresentavam limitação de abdução e 53 (66,25 por cento) tinham limitação de adução. COMENTARIOS: Os autores enfatizam o fato de que estudos recentes têm demonstrado que no interior do núcleo do VI nervo existem dois tipos de células: as que formam o nervo abducente ipsolateral e as que,...

A Case of Multiple Cranial Nerve Palsies as the Initial Ophthalmic Presentation of Antiphospholipid Syndrome

PURPOSE: To report a case of third, fourth, and six cranial nerve palsies with antiphospholipid syndrome (APS). METHODS: Medical records of a 16 year old female diagnosed with idiopathic intracranial hypertension (IIH) in primary APS were reviewed. RESULTS: A 16 year old female presented with headache and diplopia. Ocular examinations revealed marked bilateral disc edema. She was unable to depress, adduct, and abduct in left eye and had limited abduction in the right eye. Cerebrospinal fluid had a normal composition and a pressure of 400 mmH2O. Lupus anticoagulant and IgG anticardiolipin antibody were positive. There was no clinical evidence of other autoimmune disease. Brain magnetic resonance (MR) imaging, MR angiography, and conventional angiogram with venous phase were normal. She was diagnosed with bilateral sixth, and left third and fourth cranial nerve palsies secondary to idiopathic intracranial hypertension in primary APS. CONCLUSIONS: To our knowledge this is the first reported case of concurrent third, fourth, and sixth cranial nerve palsies in a patient with primary APS.

Multiple myeloma presenting as proptosis and sixth nerve palsy.

Cranial and intracranial locations are rare in multiple myeloma (MM). But their occurrence has a particular significance. Proptosis and 6th nerve palsy is very uncommon presentation. We report a case of MM with presenting features as proptosis and 6th nerve palsy.

Paresia de VI nervo congênita / Congenital VI nerve palsy

Os autores relatam caso de uma criança de 2 anos com hipótese diagnóstica de paresia de VI nervo esquerdo, congênita. O paciente foi submetido a cirurgia no olho esquerdo, com amplo retrocesso do reto medial e grande ressecçäo do reto lateral, sendo que as características peroperatórias e resultado cirúrgico reforçam a hipótese diagnóstica inicial.

Giant ocular nerve neurofibroma of the cavernous sinus: a series of 5 cases.

Five cases of giant cavernous sinus neurofibroma arising from the ocular cranial nerves are reported. These patients collected over a period of 5 years consisted of 3 males and 2 females with an age range of 9 to 40 years and a mean of 20.6 years. Clinically, all patients presented with ocular palsies over a long period (mean 3.4 years). All of them underwent a frontotemporal craniotomy along with an orbito-zygomatic osteotomy and excision of the tumour. In patients with extension of the tumour into the orbit, the superior orbital fissure was drilled, the tenon's capsule was cut and the intraorbital portion was excised. The management of these tumours is discussed and the literature reviewed.