Etiologic distribution of isolated abducens nerve palsy: Analysis of 807 patients and literature review.

BACKGROUND AND PURPOSE: The etiologies of abducens nerve palsy have shown a large variability among studies. This study aimed to establish the clinical features and underlying etiologies of isolated abducens nerve palsy by recruiting patients from all departments in a referral-based university hospital. METHODS: We reviewed the medical records of 807 patients with a confirmed diagnosis of isolated abducens nerve palsy at all departments of Seoul National University Bundang Hospital, Seongnam, Republic of Korea, from 2003 to 2020. We also compared the proportion of etiology with that of the patients pooled from the previous studies. RESULTS: The most common etiology was microvascular (n = 296, 36.7%), followed by idiopathic (n = 143, 17.7%), neoplastic (n = 115, 14.3%), vascular anomalies (n = 82, 10.2%), inflammatory (n = 76, 9.4%), and traumatic (n = 35, 4.3%). Patients were mostly managed by ophthalmologists (n = 576, 71.4%), followed by neurologists (n = 479, 59.4%), emergency physicians (n = 278, 34.4%), neurosurgeons (n = 191, 23.7%), and others (n = 72, 8.9%). The proportion of etiology significantly differed according to the age and sex of the patients and the specialties involved in the management (p < 0.001). Compared to the pooled data from the previous reports, the current study showed a higher prevalence of microvascular cause but a lower occurrence of traumatic and neoplastic causes. CONCLUSIONS: The results of previous studies on etiologic distribution of isolated abducens nerve palsy should be interpreted with consideration of the demographic features of patients recruited and the specialties involved.

Aetiologies of acquired pediatric sixth nerve palsies in a U.K. based population.

Due to the low incidence of sixth cranial nerve palsies in children, there has been limited evidence published on this subject, especially from a population based within the UK. The incidence of etiologies has been found to vary significantly within the literature, especially with regard to neoplasms. The main aim of this study is to present the etiologies of newly diagnosed pediatric sixth nerve palsies in a UK-based population. We also take into consideration if the palsies were isolated or associated with other neurological signs or symptoms. Retrospective data collection was carried out on the medical records of 50 pediatric patients with a new-onset sixth nerve palsy. They all presented to a large tertiary referral hospital in the South of the UK between 1 January 2007 and 31 December 2017. Data collected for each patient included age, gender, ethnicity, unilateral versus bilateral, other signs and symptoms, etiology, where the patient first presented, and whether the palsy was the first presenting feature. Thirty-three (66%) patients had a new-onset sixth nerve palsy in conjunction with other neurological signs or symptoms and were considered non-isolated. Seventeen cases (34%) were found to be isolated. Etiologies included high intracranial pressure (18%), neoplasm (14%), surgery for neoplasm (14%), viral (14%), infection (12%), trauma (8%), idiopathic (6%), benign space-occupying lesion (4%), congenital (2%), inflammation (2%), Alexander's disease (2%), Kawasaki syndrome (2%), and diabetes (2%). Our study found non-isolated sixth nerve palsies to be the most common presentation. These patients had a high number of potentially sinister etiologies, the most common being high intracranial pressure followed by post-surgery for neoplasm and neoplasm. Isolated sixth nerve palsies were more commonly due to viral or idiopathic etiology; however, two cases of benign space-occupying lesion and one of neoplasm were identified.

Association of Obesity and Incidence of Third, Fourth, and Sixth Cranial Nerve Palsies.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the association between obesity and the development of third, fourth, and sixth cranial nerve palsy (CNP). METHODS: We analyzed a cohort of 4,067,842 adults aged between 20 and 90 years who underwent health checkups within the National Health Insurance Service between January 1 and December 31, 2009. The participants were followed until December 31, 2017. Cox proportional hazards regression analysis was used to determine the adjusted hazard ratios (HRs) for CNP. Model 3 (the main analysis model) was adjusted for age, sex, smoking status, alcohol consumption, and physical activity. Model 4 was additionally adjusted for hypertension, dyslipidemia, and diabetes mellitus in the setting of model 3. RESULTS: A total of 5,835 individuals were diagnosed with CNP during the follow-up period (7.3 years). General obesity (body mass index [BMI] ≥25 kg/m2) was associated with an increased risk of CNP compared to individuals without general obesity (model 3, HR 1.248, 95% CI 1.184-1.315; model 4, HR 1.162, 95% CI 1.102-1.227). Abdominal obesity (waist circumference [WC] ≥90 cm in men and ≥85 cm in women) also showed an increased HR compared to individuals without abdominal obesity (model 3, 1.239, 95% CI 1.170-1.313; model 4, HR 1.127, 95% CI 1.062-1.196). Compared to the group without either type of obesity, the group with only abdominal obesity (model 3, HR 1.167, 95% CI 1.035-1.317), the group with only general obesity (HR 1.19, 95% CI 1.14-1.24), and the group with both obesity types (HR 1.317, 95% CI 1.236-1.404) showed increased HRs for CNP. CONCLUSION: Based on our population-based cohort study, both general and abdominal obesity increased the risk of CNP. Also, the combination of general and abdominal obesity may further increase the risk of CNP.

Incidence of symptomatic vertical and torsional diplopia after superior rectus transposition for esotropic Duane syndrome and abducens nerve palsy.

PURPOSE: To report the incidence of symptomatic vertical and torsional diplopia after superior rectus transposition (SRT) for esotropic Duane syndrome and abducens nerve palsy. METHODS: The medical records of patients with esotropic Duane syndrome or abducens nerve palsy seen at Boston Children's Hospital (2006-2018) and treated with unilateral SRT with or without augmentation was performed. The primary outcome was incidence of postoperative vertical or torsional diplopia in primary position. The secondary outcome was induced vertical deviation in affected side gaze. RESULTS: A total of 69 patients met inclusion criteria: 32 with abducens nerve palsy and 37 with esotropic Duane syndrome. Vertical alignment changed in both hyper- and hypotropic directions. Median pre- and postoperative vertical deviation in primary gaze was 1.1Δ (10th-90th percentile, 0Δ-6Δ hypertropia) and 0.4Δ (10th-90th percentile, 6Δ hypotropia to 8 Δ hypertropia), respectively. Postoperative vertical diplopia occurred in 7%, including 4 of 49 treated with loop myopexy (8%), 1 of 13 without augmentation (8%), and 0 of 7 treated with sclera-fixated augmentation. All but one was successfully treated with prism or secondary surgery. Intorsional change predominated, but no patient had torsional diplopia post adjustment. Vertical misalignment in affected side gaze increased from 19% to 45% after SRT (P = 0.01). CONCLUSIONS: In this largest-to-date review of patients treated with SRT, with or without MR recession, no patient developed persistent torsional diplopia, while 7% developed symptomatic vertical diplopia in primary position, similar to the reported incidence after balanced vertical rectus transposition. Vertical misalignment in affected side gaze increased, however fusion is already limited by unresolved esotropia in this field.

The Multiple Cranial Nerve Palsies: A Prospective Observational Study.

BACKGROUND: Neurological presentation with isolated multiple cranial nerve palsies is common and its diverse causes include infectious, neoplastic, and inflammatory pathologies. The aetiological spectrum may depend upon geographical regions. We undertook this study to explore clinical spectrum and aetiological profile of multiple cranial nerve palsies. METHODS: This hospital-based prospective observational study was conducted from August 2015 to August 2017. All the consecutive patients of multiple cranial palsies presenting to the neurology department were included in the studies. Primary objectives were to define anatomical syndromes/cranial nerve combinations and to establish aetiology. Secondary objectives were to study associated factors. The multiple cranial nerve palsy was defined as involvement of two or more non-homologous nerves. Patients of neuromuscular junction disorders, anterior horn cell disorders, myopathies, brain stem syndromes were excluded. All patients underwent structured protocol of clinical evaluation, investigations and few specialized investigations in accordance with clinical suspicion to establish the diagnosis. RESULTS: Fifty-four patients with a mean age of 39.9 ± 14.2 years were included. Commonest cranial nerve involved was the abducens (75.9%) among all nerve combinations. The cavernous sinus syndrome (37%), orbital apex syndrome (22.2%) and jugular foramen syndrome (11.1%) were the most frequent anatomical patterns. Infections (40.7%) were the commonest aetiology followed by neoplastic and idiopathic in four patients. CONCLUSION: Cavernous sinus syndrome was the commonest anatomical syndrome of multiple cranial nerve palsies and infections were the commonest cause in this study.

Acquired Ocular Motor Palsy: Current Demographic and Etiological Profile.

PURPOSE: To describe the clinical, demographic, and etiological profile of patients of acquired ocular motor palsy presenting in a tertiary eye care center. DESIGN: A retrospective hospital record-based study was conducted in patients of paralytic strabismus presenting from April 2016 to December 2017. METHODS: Data included demographic and clinical details, diagnosis, underlying etiology, imaging, laboratory reports, and the outcome. RESULTS: Mean age of presentation of 345 patients included in the study was 38.2 ±â€Š19.5 years (range = 365 years). Pediatric patients (age: ≤16 years) constituted 9.5% of the entire cohort. Mean duration of complaints was 5.87 ±â€Š2 months. Of the 372 eyes of 345 cases, 42.7% were sixth nerve palsy, 34.7% were third nerve palsy, 17.7% were fourth nerve palsy, and 4.8% had multiple ocular motor nerve involvement. Third and sixth nerve palsies were mostly due to ischemic event (58.1% and 69.8% cases, respectively), whereas fourth nerve palsies were commonly caused by trauma (63.6%). Amongst traumatic cases, road traffic accident was the most common mode of trauma. Systemic risk factors were preexistent in 18.2% cases (n = 63); in the remaining (40.8%; n = 141), they were diagnosed after presentation. Complete or partial recovery was noted in 69.7% cases in third nerve palsy, 67.9% cases in sixth nerve palsy, and 45% cases in fourth nerve palsy. CONCLUSIONS: Acquired cranial nerve palsy has younger onset in Indian scenario. Ischemia is the most common etiology raising concerns about the health issues of young Indians. Sixth nerve is most commonly involved in all age groups. Low recovery rate in fourth nerve palsy can be attributed to traumatic etiology.

The incidence and etiology of sixth cranial nerve palsy in Koreans: A 10-year nationwide cohort study.

We aimed to investigate the incidence, prevalence, and etiology of sixth cranial nerve (CN6) palsy in the general Korean population. The nationally representative dataset of the Korea National Health Insurance Service-National Sample Cohort from 2006 through 2015 was analyzed. The incidence and prevalence of CN6 palsy were estimated in the cohort population, confirming that incident cases of CN6 palsy involved a preceding disease-free period of ≥4 years. The etiologies of CN6 palsy were presumed using comorbidity conditions. Among the 1,108,256 cohort subjects, CN6 palsy developed in 486 patients during the 10-year follow-up. The overall incidence of CN6 palsy was estimated to be 4.66 per 100,000 person-years (95% confidence interval [CI], 4.26-5.08) in the general population. This incidence increased with age, accelerating after 60 years of age and peaking at 70-74 years of age. The mean male-to-female incidence ratio was estimated as 1.41 in the whole population, and the incidence and prevalence of CN6 palsy showed an increasing trend over time in the study period. Surgical incidence for CN6 palsy was only 0.19 per 100,000 person-years (95% CI, 0.12-0.29). The etiologies were presumed to be vascular (56.6%), idiopathic (27.2%), neoplastic (5.6%), and traumatic (4.9%). In conclusion, the incidence of CN6 palsy increases with age, peaking at around 70 years, and shows a mild male predominance in Koreans.

Infectious ocular motor neuropathies.

PURPOSE OF REVIEW: Describe the range of infectious causes of ocular motor neuropathies, from common presentations to unusual manifestations of diseases less frequently seen in the developed world. Provide information on recent developments in diagnostic testing for pathogens that may cause ocular motor neuropathies. RECENT FINDINGS: Antigen detection in serum or CSF has improved the diagnosis of cryptococcal disease. Cartridge PCR testing for tuberculosis has increased diagnostic accuracy, though tuberculous meningitis remains difficult to diagnose. Rapid, multiplex PCR and unbiased sequencing allow for diagnosis of a wider range of organisms. SUMMARY: Infectious ocular motor neuropathies can occur anywhere along the length of cranial nerves III, IV, and VI. Characteristic clinical findings and imaging can be used to localize infections. Infectious causes may have characteristic clinical, laboratory, or imaging findings, but must still be carefully separated from inflammatory or neoplastic conditions.

Oculomotor palsy in diabetics.

INTRODUCTION: Oculomotor palsy is one of the most frequent neuro-ophthalmologic complications of diabetic patients. It generates less interest in the literature than the other ocular manifestations. Our goal was to study the clinical, epidemiological, therapeutic and prognostic characteristics of oculomotor palsy in the diabetic. METHODS: This is a retrospective study of 24 diabetic patients with oculomotor palsy. The ophthalmological examination emphasized ocular motility. We performed an orthoptic assessment and a Hess-Lancaster test. Neuro-imaging was ordered in case of IIIrd and IVth nerve involvement, bilateral involvement, multiple ocular cranial nerve palsy or associated optic neuropathy. Treatment consisted of glucose management and alternating monocular occlusion or prisms for the diplopia. Data were entered and analyzed on SPSS 11.5 software. RESULTS: The mean age of the patients was 58.5±11.9 years. Binocular diplopia was the main symptom. The oculomotor palsy involved the VIth nerve in 50% of cases and was bilateral in two cases. Three patients also had an optic neuropathy. The mean duration of diabetes was 11.7±11 years; poorly controlled diabetes was found in 75% of cases and an association with diabetic retinopathy was noted in 56% of cases. CONCLUSIONS: Long-standing uncontrolled type 2 diabetes, hypertension, coronary artery disease, left ventricular hypertrophy, and elevated hematocrit are the most common risk factors. The VIth nerve is commonly involved. Certain characteristics of the pupillary light reflex can help to differentiate an ischemic insult from an aneurysmal injury to the IIIrd nerve.

Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy.

BACKGROUND: Pituitary apoplexy (PA) often presents with acute headache and neuro-ophthalmic manifestations, including ocular motility dysfunction (OMD) from cranial nerve palsies (CNPs). Our goal was to describe the epidemiology and outcomes of OMD in a large, single-center series of patients with PA. METHODS: We conducted a retrospective chart review of all patients with PA seen in our pituitary center between January 1995 and December 2012. Presenting neuro-ophthalmic, endocrine, and radiologic data, as well as neuro-ophthalmology follow-up data, were collected. RESULTS: We identified 235 patients with PA, 59 of whom (25%) had OMD. Twenty-seven of those 59 patients underwent neuro-ophthalmic evaluation. Preoperatively, 23 of these 27 patients had unilateral OMD, 18 (78%) with a single CNP and 5 (22%) with multiple CNPs. Bilateral OMD was present in 4 of the 27 patients. Postoperatively, 24 of the 27 patients with OMD had follow-up (median duration, 7 months; interquartile range [IQR], 3-17 months). At the last postoperative follow-up, 7 of these 24 patients (29%) had OMD (5 unilateral, 2 bilateral). OMD resolved in 3 of the 24 patients (12%) within 1 month, in 13 of 21 patients (62%) within 6 months (3 lost to follow-up), and in 17 of 19 patients (89%) within 1 year (2 lost to follow-up). Surgery was performed at ≤14 days after presentation in 16 of 18 (89%) resolved cases and in 4 of 6 (67%) unresolved cases. Patients with OMD were more likely than those without OMD to have larger tumors (2.6 vs. 2.0 cm; P < 0.001), panhypopituitarism (31% vs. 14%; P = 0.005), and necrosis (58% vs. 37%; P = 0.03). CONCLUSIONS: OMD from CNPs is common in PA, occurring in one-quarter of patients, and is frequently associated with certain radiologic, endocrinologic, and pathological features. The prognosis is excellent, with 90% of cases of OMD resolving by 1 year after early pituitary surgery.

Ocular Movement Nerve Palsy After Mild Head Trauma.

BACKGROUND: Ocular movement nerve (cranial nerve III, IV and VI) palsy (OMNP) is rarely encountered after mild head trauma. As a result of the inconsistent definition of this specific entity in published studies, it is difficult to offer an accurate management strategy and prognosis assessment to affected patients. METHODS: A retrospective review of the medical records of the patients at the First Hospital of Jilin University combined with a systematic review of published studies was conducted. RESULTS: Thirty-one patients (17 females, 55%), including 6 cases in our institution, were identified in this systematic review. Cranial nerves III, IV, and VI were involved in 54.8%, 3.2%, and 45.2% of the patients, respectively. Although all the patients in our case series experienced complete resolution, only 54.6% experienced complete resolution in a time course of 10 days to 13 months. Additional intracranial findings other than traumatic brain injury on imaging modalities that might predispose to OMNP after mild head trauma were identified in 25.8% of the patients. CONCLUSIONS: OMNP after mild head trauma is a rare entity in neurosurgical practice. In patients with no positive intracranial finding, observation and follow-up are the mainstay of management. If any underlying intracranial lesions are identified, the management should be focused on the underlying lesions. From the data available, mild trauma does not mean mild injury or favorable recovery in OMNP after mild head trauma.

Prevalence of Diabetic Retinopathy in a Population of Diabetics From the Middle East With Microvascular Ocular Motor Palsies.

BACKGROUND: Vascular risk factors are increasing rapidly in the Middle East. Growing inactivity and obesity have contributed to an epidemic of Type 2 diabetes mellitus (DM) in the Arab population. Microvascular palsies of the third, fourth, and sixth cranial nerves, which occur in an isolated manner, are relatively common in patients with DM, hypertension, or other vascular risk factors. METHODS: In this retrospective analysis, patients with diabetes with microvascular palsies were assessed for the prevalence of diabetic retinopathy (DR). We compared these data with the prevalence of DR in the general population of diabetics in Saudi Arabia and to a similar published study done in an American population. RESULTS: In total, 126 patients with diabetes were included in the study. The sixth nerve was most frequently involved in 67 patients (53%). Seventy-seven patients (61%) had DR, compared with 49 (39%) without DR. The prevalence of DR in the general population of Saudi patients with diabetes ranged from 30% to 36.1%. CONCLUSIONS: Our study demonstrated a higher prevalence of DR in patients with microvascular palsies compared with the general population of patients with diabetes in the Arab population. This is in contrast to a previous study in an American population. Our results might be secondary to differences between the 2 populations, in particular, the continued increase in the prevalence of vascular risk factors (mainly diabetes) and poor control of these risk factors in the Middle East.

Increased Risk of Stroke in Patients with Isolated Third, Fourth, or Sixth Cranial Nerve Palsies: A Nationwide Cohort Study.

BACKGROUND AND PURPOSE: The aim of this nationwide cohort study was to evaluate whether the occurrence of isolated 3rd, 4th or 6th cranial nerve (CN) palsies is associated with a higher risk of ischemic stroke. METHODS: This study utilized data from Taiwan Longitudinal Health Insurance Database during 1995-2012. Subjects aged 20 years or older who had isolated CN 3/4/6 palsies diagnosed by a neurologist or ophthalmologist between January 2000 and December 2011 were included. A set of propensity score matched, randomly sampled patients who had never been diagnosed with CN 3/4/6 palsies were extracted to constitute the control group (cases and controls = 1:4). All subjects were followed until death, loss due to follow-up or completion of the study. Cox proportional hazard regression model stratified by matched pairs was used to estimate the hazards ratio (HR) of ischemic stroke. RESULTS: A total of 657 patients with isolated CN 3/4/6 palsies (61.1% male, mean age 54.8 years) were identified. Compared with control group, the patients with isolated CN 3/4/6 palsies exhibited an increased risk of ischemic stroke (CN3: adjusted HR 3.69 (95% CI 2.20-6.19); CN4: 2.71 (95% CI 1.11-6.64); CN6: 2.15 (95% CI 1.31-3.52)). The association between CN 3/4/6 palsies and ischemic stroke was detected in both separate subgroup and sensitivity analyses. CONCLUSIONS: The patients with CN 3/4/6 palsies exhibited an increased risk of developing ischemic stroke. Therefore, isolated ocular motor nerves palsies appear to represent an unrecognized risk factor for ischemic stroke, and these require further confirmation and exploration.

Strategy for the surgical treatment of vestibular schwannomas in patients with neurofibromatosis type 2.

OBJECTIVE: Guidelines for appropriate management of vestibular schwannomas in NF2 patients are controversial. In this paper we reviewed our experience with patients with NF2 for the results of surgical treatment with particular reference to hearing and facial nerve preservation. METHODS: We included in the study 30 patients (16 women and 14 men) with the diagnosis of NF2 treated in our department between 1998 and 2014 who underwent surgery for vestibular schwannoma removal with a follow-up for at least 1 year. In 3 cases, the vestibular schwannomas were unilateral. Six patients with bilateral vestibular schwannomas underwent unilateral procedure. Therefore, 51 acoustic tumors were studied in 30 patients. RESULTS: No operative death we noted. Significant deterioration to the non-functional level occurred in 19 out of 22 cases with well-preserved preoperative hearing. Only three ears maintained their preoperative good hearing. Hearing was preserved in cases of small schwannoma not exceeding 2 cm. Among 21 patients who underwent bilateral operations hearing was preserved in 3 out of 7 cases when smaller tumor or better hearing level side was attempted at first surgery. In contrary none of the 14 patients retained hearing when the first operation concerned the worse-hearing ear. Among 14 tumors up to 2 cm there was only one case of moderately severe facial nerve dysfunction (House-Brackmann Grade IV) in the long follow-up. CONCLUSION: Early surgical intervention for vestibular schwannoma in NF2 patient is a viable management strategy to maintain hearing function and preserve facial nerve function.

Cranial nerve VI palsy after dural-arachnoid puncture.

In this article, we provide a literature review of cranial nerve (CN) VI injury after dural-arachnoid puncture. CN VI injury is rare and ranges in severity from diplopia to complete lateral rectus palsy with deviated gaze. The proposed mechanism of injury is cerebrospinal fluid leakage causing intracranial hypotension and downward displacement of the brainstem. This results in traction on CN VI leading to stretch and neural demyelination. Symptoms may present 1 day to 3 weeks after dural-arachnoid puncture and typically are associated with a postdural puncture (spinal) headache. Resolution of symptoms may take weeks to months. Use of small-gauge, noncutting spinal needles may decrease the risk of intracranial hypotension and subsequent CN VI injury. When ocular symptoms are present, early administration of an epidural blood patch may decrease morbidity or prevent progression of ocular symptoms.

Risk factors and prognosis of isolated ischemic third, fourth, or sixth cranial nerve palsies in the Korean population.

BACKGROUND: To investigate the risk factors and prognosis for ischemic third, fourth, and sixth cranial nerve palsies in a Korean population. METHODS: A pair-matched case-control study of 54 Korean patients who were diagnosed with ischemic third, fourth, or sixth cranial nerve palsies was performed to evaluate their risk factors. Using conditional logistic regression analysis, prevalence of potential risk factors in patients and controls, included diabetes mellitus, hypertension, hyperlipidemia, ischemic heart disease, left ventricular hypertrophy (LVH), and smoking were examined retrospectively. A cohort study by Kaplan-Meier method was performed to analyze the recovery period in relation to the number of risk factors or intracranial abnormalities detected by brain computed tomography or magnetic resonance imaging. RESULTS: The mean age of onset was 64.5 years. Of the 54 patients, 16 (29.6%) developed a third nerve palsy, 19 (35.2%) a fourth nerve palsy, and 19 (35.2%) a sixth nerve palsy. The risk factors of diabetes mellitus, hypertension, and hyperlipidemia were significantly more prevalent than other risk factors of heart disease, LVH, and smoking. The mean number of risk factors was 2.3 ± 0.6 in the third nerve palsy group, 1.7 ± 0.9 in the fourth nerve palsy group, and 1.6 ± 1.0 in the sixth nerve palsy group. Patients with 2 or more risk factors showed a longer recovery period (9.0 ± 5.1 weeks) than did patients who had 1 risk factor (6.1 ± 2.2 weeks). Patients with intracranial abnormalities on neuroimaging showed a longer recovery time (10.4 ± 2.7 weeks) than did those without intracranial abnormalities (7.5 ± 4.8 weeks). CONCLUSIONS: Ischemic ocular motor cranial nerve palsy is closely related to diabetes mellitus, hypertension, and hyperlipidemia in Korean patients. Compared with the fourth or sixth nerve palsy groups, the third nerve palsy group showed a tendency to have multiple risk factors. Recovery takes longer when 2 or more risk factors were present or when abnormal findings were observed on neuroimaging.

Bilateral abducens nerve palsy associated with subarachnoid hemorrhage.

OBJECTIVE: Isolated abducens nerve palsies associated with intracranial aneurysms have rarely been reported. The purpose of the study was to study the patients with bilateral abducens nerve palsy in association with subarachnoid hemorrhage (SAH). METHODS: All patients admitted and managed at our center with a diagnosis of SAH and had bilateral abducens nerve palsy were included in the study. The demographic and clinical details, radiological findings, treatment data, and outcome of these patients were retrieved from the computerized database of our hospital. RESULTS: Nine patients, with a mean age of 49.4 years, met the inclusion criteria. Male to female ratio of 1.25:1). Average duration of symptoms before presentation was 2.6 days (ranging from 1 to 4 days). Third nerve palsy in addition to bilateral abducens nerve palsy was present in 4 patients (44%). DSA demonstrated aneurysms in 7 patients; 4 had posterior circulation aneurysms and 3 had aneurysms of anterior circulation. Two patients had angionegative SAH. The abnormality resolved in all but one patient over a time period of 4-9 weeks, and one patient died due to unrelated cause. CONCLUSIONS: Bilateral abducens nerve palsy in association with SAH is rarely described. Proposed mechanisms include direct compression of the bilateral abducens nerves, vasospasm of the pontine branches of the basilar artery and hydrocephalous. Most of the patients in our series showed resolution of the symptoms over a period of 4-9 weeks.

Recovery of ophthalmoplegia after endovascular treatment of intracranial aneurysms.

BACKGROUND AND PURPOSE: Recovery of aneurysm induced CNP after endosaccular coiling has been reported in the literature. The aim of this study was to assess in detail the parameters that affect the outcome after endovascular treatment of ophthalmoplegic aneurysms due CNP. MATERIALS AND METHODS: Between November 1999 and March 2008, 30 consecutive patients (8 men, 22 women; mean age, 54.9 years) presenting with CNP underwent endosaccular coiling with or without additional use of stents in the parent artery. Subarachnoid hemorrhage was present in 10 patients, whereas 20 patients had unruptured aneurysms. The mean size of the aneurysms was 10 mm. Initial CNP was complete in 11 patients and partial in 19. Mean follow-up after coiling was 19 months. RESULTS: The mean interval between the onset of CNP and aneurysm embolization was 48 days. Fifteen patients (50%) had complete recovery of oculomotor function, 12 had incomplete recovery (40%), and 3 (10%) remained unchanged after treatment. In 4 aneurysms (13.3%), 1 additional embolization was performed, whereas in 4 other aneurysms, 2 additional embolization procedures were necessary. Procedure-related permanent morbidity occurred in 2 patients (6.6%). CONCLUSIONS: Endosaccular coiling is an effective and safe method for the treatment of ophthalmoplegic aneurysms. Age, neck size, and time of treatment do not seem to constitute prognostic factors with respect to CNP recovery, though patients with small aneurysms, unruptured status, and/or location in the posterior circulation showed a tendency for better outcome. The degree of initial CNP was the only statistically significant prognostic factor concerning the final outcome, resulting in better recovery, in case of incomplete initial CNP.

[Postoperative results in VI nerve palsy]. / Rezultate postoperatorii în paralizia de nerv VI.

This study analyze the surgical results obtained in a lot of patients with sixth nerve paralysis operated with different techniques. The results were evaluated using the following parameters: deviation in primary position, abduction deficit, existence of induced vertical deviation and presence of anterior segment ischemia. Ortotropia was achieved in higher percentage in full tendon transposition technique, closely followed by recession-resection technique; the weakest results were recorded in partial tendon transposition technique. Similar results were obtained in abduction improvement. The induced vertical deviation was present in higher percentage in partial transposition technique. The anterior segment ischemia wasn't recorded in any case regardless of the selected surgical technique. Careful analysis of the ocular motility deficit (paresis or palsy) is crucial in selecting the appropriate surgical procedure.

Ophthalmoplegia with migraine in adults: is it ophthalmoplegic migraine?

OBJECTIVE: Ophthalmoplegic migraine (OM) is a rare disorder characterized by recurrent oculomotor nerve palsy in children, following migraine headaches. We report 62 adults, seen consecutively, who developed acute ophthalmoplegia with severe attacks of migraine over a 10-year (1996-2005) period. An overwhelming majority of these patients had an antecedent worsening in severity of migraine headaches, before the ophthalmoplegic attack. METHODS: Sixty-two patients, aged 15-68 years, with an acute attack of OM underwent detailed clinical, biochemical, and neuroradiological evaluation. RESULTS: There were 62 patients with 86 attacks of OM. Whereas 48 patients had a single attack, 14 had 2 or more attacks, fulfilling the International Headache Society criteria for probable and definite OM, respectively. At presentation, isolated abducens, oculomotor, and trochlear nerve involvements were seen in 35 (56.5%), 21 (33.9%), and 5 (8.1%) patients, respectively. One patient had simultaneous involvement of 3rd and 6th nerves. Fifty-one (82.3%) patients exhibited an antecedent worsening in severity of migraine, before developing ophthalmoplegia during (59/95.2%) or within 24 hours (3/4.8%) of a severe migraine attack, respectively. Detailed biochemistry and cranial neuroimaging were normal. No case had any nerve enhancement. Use of steroids hastened recovery (P < .05). CONCLUSION: We conclude: (1) OM in adults is characterized by single attacks of ophthalmoplegia in a great majority of patients; and (2) 6th nerve involvement occurs commonly. Our results indicate that moving OM to the chapter on cranial neuralgias in the second edition of the International Headache Classification may be premature, since nerve palsy occurred during a severe migraine attack in all patients.