Carotid-cavernous fistula: A potential treatable cause of bilateral abducens palsy and conjunctival hyperemia.

OBJECTIVE: Carotid cavernous fistulas (CCFs) represent uncommon and anomalous communications between the carotid artery and the cavernous sinus. MATERIALS AND METHODS: Case report RESULTS: We present the clinical details and successful management of a previously healthy 44-year-old patient who presented with one-month worsening headache, bilateral abducens palsy and conjunctival injection. Imaging modalities including magnetic resonance imaging (MRI) with contrast and digital subtraction angiography (DSA) facilitated the diagnosis of CCF. The patient underwent endovascular coiling of the CCF, leading to neurological recovery and symptom remission. CONCLUSION: This case highlights the importance of promptly CCF diagnosis in patients with multiple cranial nerve palsies and conjunctival hyperemia. Moreover, it emphasizes the efficacy of endovascular coiling in achieving symptom remission.

Vertebrobasilar dolichoectasia and other arterial abnormalities leading to abducens nerve palsy.

INTRODUCTION: Dolichoectatic vessels can cause cranial nerve dysfunction by either direct compression or ischemia. Abducens nerve palsy due to neurovascular compression by elongated, enlarged, tortuous or dilated arteries is an uncommon but important cause. AIM: To highlight neurovascular compression as a cause of abducens nerve palsy and discuss various diagnostic techniques. METHODS: Manuscripts were identified using the National Institutes of Health PubMed literature search system. Search terms included abducens nerve palsy, neurovascular compression, dolichoectasia and arterial compression. Inclusion criteria required that the articles were written in English. RESULTS: The literature search identified 21 case reports where abducens nerve palsy was due to vascular compression. Out of these 18 patients were male and the mean age was 54 years. Eight patients had unilateral right abducens nerve involvement; eleven patients had unilateral left nerve involvement and two patients had bilateral involvement. The arteries causing the compression were basilar, vertebral and anterior inferior cerebellar arteries. A compressed abducens nerve is not usually clearly detected on CT (Computed Tomography) or MRI (Magnetic Resonance Imaging). MRA (Magnetic Resonance Angiography), Heavy T2- WI (weighted imaging), CISS (constructive interference in steady state) and FIESTA (Fast Imaging Employing Steady-state Acquisition) are essential to demonstrate vascular compression of the abducens nerve. The various treatment options included controlling hypertension, glasses with prisms, muscle resection and microvascular decompression.

Acupuncture for abducens nerve palsy after radiochemotherapy: a CARE-compliant case report.

BACKGROUND: Delayed abducens nerve palsy after chemoradiotherapy for nasopharyngeal carcinoma (NPC) is often accompanied by ocular ischemia and cranial nerve damage, thereby increasing the risk of conventional strabismus surgery. Therefore, patients often prefer conservative treatment. Herein we report a case of acupuncture for delayed abducens nerve palsy after chemoradiotherapy for NPC. CASE PRESENTATION: A 39-year-old patient who previously received chemotherapy and radiotherapy for NPC developed a unilateral abducens nerve palsy with numbness in the face and stiffness in the neck muscles after six years. Based on magnetic resonance imaging (MRI), medical history, and physical examination, he was diagnosed with abducens nerve palsy after chemoradiotherapy. The acupuncture treatment regimen was mainly based on periocular electroacupuncture, supplemented with wheat grain moxibustion and warming needle moxibustion, which were performed three times a week. After one month with a total of 17 acupuncture sessions, the patient's affected eye abduction function recovered completely. Facial sensory abnormalities and neck stiffness also improved significantly. Follow-up at two months reported no recurrence. CONCLUSION: Acupuncture may be a conservative treatment option for patients with abducens nerve palsy after chemoradiotherapy.

Computational method for aid in the diagnosis of sixth optic nerve palsy through digital videos.

The sixth cranial nerve, also known as the abducens nerve, is responsible for controlling the movements of the lateral rectus muscle. Palsies on the sixth nerve prevent some muscles that control eye movements from proper functioning, causing headaches, migraines, blurred vision, vertigo, and double vision. Hence, such palsy should be diagnosed in the early stages to treat it without leaving any sequela. The usual methods for diagnosing the sixth nerve palsy are invasive or depend on expensive equipment, and computer-based methods designed specifically to diagnose the aforementioned palsy were not found until the publication of this work. Therefore, a low-cost, non-invasive method can support or guide the ophthalmologist's diagnosis. In this context, this work presents a computational methodology to aid in diagnosing the sixth nerve palsy using videos to assist ophthalmologists in the diagnostic process, serving as a second opinion. The proposed method uses convolutional neural networks and image processing techniques to track both eyes' movement trajectory during the video. With this trajectory, it is possible to calculate the average velocity (AV) in which each eye moves. Since it is known that paretic eyes move slower than healthy eyes, comparing the AV of both eyes can determine if the eye is healthy or paretic. The results obtained with the proposed method showed that paretic eyes move at least 19.65% slower than healthy ones. This threshold, along with the AV of the movement of the eyes, can help ophthalmologists in their analysis. The proposed method reached 92.64% accuracy in diagnosing the sixth optic nerve palsy (SONP), with a Kappa index of 0.925, which highlights the reliability of the results and gives favorable perspectives for further clinical application.

Flow diverter stents for pediatric traumatic carotid cavernous fistula: a case report and literature review.

A 10-year-old, male patient with a head injury caused by a fall presented with chemosis, exophthalmos, right orbital bruit, and intracranial venous reflux, based on which posttraumatic carotid cavernous fistula (CCF) was diagnosed. Coil embolization was semi-urgently performed for the dangerous venous drainage. After the treatment, right abducens nerve palsy newly appeared. To treat the neurological symptoms and preserve the parent artery, curative endovascular treatment using a pipeline embolization device (PED) with coil embolization was performed after starting dual antiplatelet therapy (DAPT). The CCF and abducens nerve palsy finally resolved, and the internal carotid artery (ICA) was remodeled. Use of the PED with adjunctive coil embolization was effective and safe in the present case of pediatric traumatic direct CCF.

Sixth cranial nerve palsy secondary to compression by dolichoectatic vertebrobasilar artery.

Dolichoectasia refers to distinct elongation, dilatation and tortuosity of an artery. We present a rare well-illustrated case of dolichoectatic vertebrobasilar artery compressing the cisternal portion of the sixth cranial nerve resulting in chronic sixth nerve palsy. High spatial resolution, three-dimensional, heavily T2-weighted MRI sequences are uniquely positioned to assess the cranial nerves especially in their cisternal and canalicular portions and need to be performed for all patients with non-resolving cranial nerve palsies. Dolichoectatic vessels can be the cause of neurovascular conflict and cause non-resolving oculomotor palsies.

Using Botulinum Toxin A as an Adjunct in the Surgery of Large-Angle Sensory Exotropia and Abducens Nerve Palsy.

Regarding the review article by Escuder AG, Hunter DG, entitled "The Role of Botulinum Toxin in the Treatment of Strabismus" Seminars in Ophthalmology. 2019;34(4): 198-204, we cannot agree with you more with your point of view about the dosage preparation for botulinum toxin A (BTA) in the strabismus surgery. Moreover, we also included a case series that used BTA as an adjunct in the surgery for large-angle sensory exotropia and abducens nerve palsy.

Procedimiento de Nishida asociado a toxina botulínica en parálisis completa del sexto par craneal bilateral de larga evolución / Nishida procedure associated with botulinum toxin in a long-standing complete bilateral sixth cranial nerve palsy

En los casos graves de parálisis del abducens o sexto par craneal resultan útiles las transposiciones de rectos superiores y rectos inferiores hacia el recto lateral paralítico. Se han descrito numerosas técnicas a lo largo del tiempo para la realización de estas transposiciones, como son las de Hummelsheim, O’Connor, Jensen, Foster o Nishida. Las 4 primeras llevan aparejado un aumento del riesgo de isquemia del segmento anterior. Presentamos el caso de una parálisis de sexto par craneal bilateral de larga data de evolución, secundaria a un traumatismo craneoencefálico grave. Para minimizar el riesgo de isquemia del segmento anterior se optó por la realización de la técnica de Nishida, asociada a inyección de toxina botulínica en ambos rectos medios para tratar de resolver la contractura muscular asociada a la larga evolución del caso, obteniendo buenos resultados a los 6 y 12 meses del procedimiento quirúrgico

In severe cases of abducens or sixth cranial nerve palsy, transpositions of the superior rectus and inferior rectus into the paralytic lateral rectus have been demonstrated to be useful. Numerous techniques have been described over time to carry out these transpositions, such as the Hummelsheim, O’Connor, Jensen, Foster, or Nishida technique. The first 4 techniques mentioned above have an increased risk of anterior segment ischaemia. The case is presented of a long-standing bilateral sixth cranial nerve palsy secondary to a severe cranial injury. Given the risk of ischaemia of the anterior segment, the Nishida technique was chosen in order to reduce the risk of suffering from this complication. This is combined with botulinum toxin in both middle rectus to try to resolve the muscle contracture associated with the long evolution of the case, obtaining good results at 6, and 12 months after the surgical procedure

Nishida procedure associated with botulinum toxin in a long-standing complete bilateral sixth cranial nerve palsy. / Procedimiento de Nishida asociado a toxina botulínica en parálisis completa del sexto par craneal bilateral de larga evolución.

In severe cases of abducens or sixth cranial nerve palsy, transpositions of the superior rectus and inferior rectus into the paralytic lateral rectus have been demonstrated to be useful. Numerous techniques have been described over time to carry out these transpositions, such as the Hummelsheim, O'Connor, Jensen, Foster, or Nishida technique. The first 4 techniques mentioned above have an increased risk of anterior segment ischaemia. The case is presented of a long-standing bilateral sixth cranial nerve palsy secondary to a severe cranial injury. Given the risk of ischaemia of the anterior segment, the Nishida technique was chosen in order to reduce the risk of suffering from this complication. This is combined with botulinum toxin in both middle rectus to try to resolve the muscle contracture associated with the long evolution of the case, obtaining good results at 6, and 12 months after the surgical procedure.

Isolated Abducens Nerve Palsy Associated with Ruptured Posterior Inferior Cerebellar Artery Aneurysm: Rare Neurologic Finding.

BACKGROUND: Isolated abducens nerve palsy can be the presenting sign of a ruptured PICA aneurysm. Few cases have been reported in the literature. In the majority of cases, cranial nerve VI resolved following microsurgical clipping. CASE DESCRIPTION: Here, we report a 56-year-old female who presented with a ruptured 4 mm × 3 mm left PICA aneurysm associated with a left abducens nerve palsy. The patient underwent endovascular coil embolization of the aneurysm and had complete resolution of her abducens nerve palsy. CONCLUSIONS: Here, we present the first case of an abducens nerve palsy associated with a ruptured PICA aneurysm to completely resolve following endovascular coil embolization. The direction and amount of subarachnoid hemorrhage extravasation from the ruptured aneurysm are most likely responsible for cranial nerve palsy.

Isolated Oculomotor and Abducens Nerve Palsies as Initial Presentation of Cavernous Sinus Tuberculoma: Case Report and Literature Review.

BACKGROUND: Central nervous system tuberculoma is the most severe manifestation of extrapulmonary tuberculosis with high mortality. Cavernous sinus tuberculoma (CST) is a very rare central nervous system tuberculoma with few cases reported in the literature. CASE DESCRIPTION: A 57-year-old woman was admitted to our clinic with acute diplopia and headache limited to the right side. There was no specific medical history except for migraine, depression, and anxiety, all of which were controlled by oral medications. Physical examination revealed ptosis and mydriasis in the right eye, which indicated right third and sixth cranial nerve palsies. Pituitary magnetic resonance imaging showed a right parasellar lesion at the cavernous sinus wall and ophthalmic nerve. Laboratory examinations and brain computed tomography scan showed negative findings. Initial differential diagnosis included meningioma, sarcoidosis, tuberculoma, and lymphoma. However, results of further studies, including blood and cerebrospinal fluid cultures and Mycobacterium tuberculosis DNA assay, were negative. Biopsy of the cerebral lesion was performed through the subfrontal approach, and histopathologic study confirmed CST. She was treated with a standard antituberculous regimen. After 12 months of follow-up, no cerebral or clinical findings were seen. CONCLUSIONS: CST is a rare presentation of M. tuberculosis, and the diagnosis is a difficult challenge. However, accurate diagnosis and timely treatment of CST can result in complete cure.

Cerebral vasculitis and lateral rectus palsy - two rare central nervous system complications of dengue fever: two case reports and review of the literature.

BACKGROUND: Dengue fever is a common mosquito-borne viral illness with a clinical spectrum ranging from a simple febrile illness to potentially life-threatening complications such as dengue hemorrhagic fever and dengue shock syndrome. Dengue infection can affect many organs, including the central nervous system. The neurological manifestations reported in dengue infections are meningitis, encephalitis, stroke, acute disseminated encephalomyelitis, and Guillain-Barré syndrome. CASE PRESENTATION: We report the cases of two interesting patients with confirmed dengue infection who presented with complications of possible central nervous system vasculitis and cranial nerve palsy. The first patient was a 53-year-old previously healthy Singhalese woman who developed acute-onset slurring of speech and ataxia with altered sensorium 1 day after recovery from a critical period of dengue hemorrhagic fever. Subsequent investigations revealed evidence of encephalopathy with brainstem ischemic infarctions. Her clinical picture was compatible with central nervous system vasculitis. She was treated successfully with intravenous steroids and had a full functional recovery. The second patient was a middle-aged Singhalese woman who had otherwise uncomplicated dengue infection. She developed binocular diplopia on day 4 of fever. An ocular examination revealed a convergent squint in the left eye with lateral rectus palsy but no other neurological manifestation. CONCLUSIONS: Central nervous system vasculitis due to dengue infection is a very rare phenomenon, and to the best of our knowledge, only one case of central nervous system vasculitis has been reported to date, in a patient of pediatric age. Cranial nerve palsy related to dengue infection is also rare, and only a few cases of isolated abducens nerve palsy have been reported to date. The two cases described in this report illustrate the rare but important central nervous system manifestations of dengue fever and support the fact that the central nervous system is one of the important systems that can be affected in patients with dengue infection.

[Cerebrospinal fluid leakage and abducens nerve palsy caused by bowling activity].

Cerebrospinal fluid leakage can develop due to traffic trauma or lumbar puncture; however, in many cases, it develops spontaneously without any obvious cause. This report describes a case of cerebrospinal fluid leakage caused by bowling activity. A 57-year-old woman adjusted her bowling form, which led to the development of an orthostatic headache and double vision. Cerebrospinal fluid leakage and right abducens nerve palsy was diagnosed, which was resistant to conservative treatment. An epidural blood patch was performed, leading to an improvement in the headache and abducens nerve palsy. The hypotension and nerve palsy may have been caused by small amounts of cerebrospinal fluid leakage due to repeated traction of the brachial plexus and nerve root resulting from an irregular bowling form. To the best of our knowledge, there are no reported cases of cerebrospinal fluid leakage caused by bowling; therefore, this is a valuable case to investigate the mechanism of onset. Similar mechanisms may have remained undiscovered in other cases of spontaneous intracranial hypotension.

Novel Segmentation of Placed Coils in the Treatment of Cavernous Sinus Dural Arteriovenous Fistulas Provides a Reliable Predictor of the Long-Term Outcome in Abducens Nerve Palsy.

OBJECTIVE: Abducens nerve palsy (ANP) after transvenous embolization (TVE) for cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) sometimes persists. The aim of this study was to assess the correlation between the coil mass and the long-term outcome of ANP after TVE. METHODS: Between January 2008 and July 2016, 33 patients with a CS DAVF underwent TVE at our institute. On the basis of the relationship to the internal carotid artery (ICA), we divided the lateral part of the CS into the following 3 portions: anterolateral, anterolateral to the anterior bend of the ICA; middle-lateral (ML), lateral to the horizontal segment of the ICA; and posterolateral, posterolateral to the posterior bend of the ICA. RESULTS: ANP persisted in 4 patients. The number of coils (35.3 vs. 21.9 coils; P = 0.04), coil volume (198.4 vs. 103.6 mm3; P = 0.03), and coil volume in the ML (54.9 vs. 20.3 mm3; P = 0.01) were significantly greater in the ANP group than in the non-ANP group. In the logistic regression analysis, only the ML coil volume was significantly associated with the persistence of ANP (P = 0.04). Based on the receiver operating characteristic curve, the optimal cutoff value of the ML coil volume was 27.9 mm3 (sensitivity, 100%; specificity, 72.4%). CONCLUSIONS: Overpacking in the ML of the CS should be avoided to prevent persistent ANP. The cutoff value of the ML coil volume may provide a good guide for the practical use of TVE for CS DAVFs.

The changing face of petrous apicitis-a 40-year experience.

OBJECTIVES/HYPOTHESIS: Petrous apicitis (PA) is a rare complication of otitis media. Gradenigo syndrome, with the classic triad of otitis, deep pain, and abducens paralysis, is rarer still. The objective of this study was to determine if clinical presentation and management has changed over time. STUDY DESIGN: Retrospective chart review. METHODS: Forty-four patients with PA over a 40-year period were studied. Symptoms, signs, and management outcomes were studied. Historical review, surgical anatomy and approaches, pathology, and microbiology, and an illustrative case are included as appendices. RESULTS: The classical Gradenigo triad of retro-orbital pain, otitis, and abducens palsy occurred in only six of 44 patients (13.6%). Over the 40-year observation period, those needing surgery has decreased. CONCLUSIONS: Antibiotics remain the primary treatment modality. Surgery is reserved for cases failing to respond to antibiotics. One of the 44 patients in this series died of his disease. Diagnosis and management algorithms based on these observations are suggested. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:195-201, 2018.