Central pontine myelinolysis presenting as isolated sixth nerve palsy in third trimester of pregnancy

A 30-year-old primigravida presented with isolated left sixth nerve palsy at 38 weeks gestation. Her MRI showed a lesion consistent with central pontine myelinolysis (CPM). Extensive investigations did not reveal any secondary cause for the CPM. She recovered spontaneously in 2 weeks with complete resolution of her MRI changes. To our knowledge, this is the first report of CPM occurring in third trimester in the absence of identifiable secondary causes and of CPM presenting as an isolated sixth nerve palsy. We discuss the reported causes of CPM in pregnancy, possible pathophysiologic mechanisms involved and the anatomic basis of the unique clinical presentation of sixth nerve palsy in our case.     

Predicting comorbidities with neuroimaging in children with cerebral palsy

A population-based registry was used to ascertain whether neuroimaging findings of children with cerebral palsy could predict the occurrence of certain comorbidities. Neuroimaging findings and comorbidities data were extracted from the Quebec Cerebral Palsy Registry for children born in a 4-year birth interval (1999-2002) covering half of the province’s population. Neuroimaging studies were classified into 10 mutually exclusive categories (periventricular white matter injury/leukomalacia, cerebral malformation, cerebral vascular accident, deep gray matter injury, superficial gray matter injury, diffuse gray matter injury, intracranial hemorrhage, infection, nonspecific findings, and normal). Comorbidities studied included cortical blindness, severe auditory impairment, inability to communicate verbally, assisted feeding, and the presence of afebrile seizures in the prior 12 months. Neuroimaging results were available for a total of 213 children. Only deep gray matter injury (defined as signal abnormality or volume loss in subcortical gray matter, n = 9) was significantly (P < 0.05) linked with the occurrence of both the inability to communicate verbally (n = 5, 55.6% vs n = 46, 22.5%, P = 0.04) and with a higher mean number of comorbidities (1.67 vs 0.70, P < 0.01), and therefore with increased burden of comorbidities. These findings may improve our ability to prognosticate the outcome of children with cerebral palsy, enabling targeted early direct interventions.     

Sudden death from pituitary apoplexy in a patient presenting with an isolated sixth cranial nerve palsy.

A 68-year-old diabetic, hypertensive man presented with a left sixth cranial nerve palsy. MRI demonstrated an inhomogeneous sellar mass encroaching on the left cavernous sinus. Two days later, a left third cranial nerve palsy developed. Within 24 hours, the patient went into cardiac arrest and died. An autopsy showed hemorrhage within a pituitary macroadenoma ("pituitary apoplexy"). Pituitary apoplexy should be considered a cause of acute isolated sixth cranial nerve palsy and may represent a life-threatening emergency that can be averted with emergent hormonal replacement and hypophysectomy.     

Bilateral sixth nerve palsy. Analysis of 125 cases.

Bilateral abducens nerve pareses were nearly as common as unilateral cases in an inpatient setting (125:143). Cerebrospinal fluid abnormalities were more frequent among the bilateral cases, but generally the same causes produced unilateral and bilateral sixth nerve palsy. The relative ease of diagnosis was in contrast with the large number of undiagnosed or "vascular" cases in previous studies of outpatients. The degree of lateral rectus limitation proved to be of limited help in suggesting the cause or predicting recovery of oculomotor function. The etiology was of some prognostic value, with universal recovery of pressure palsies and rare improvement with tumor involvement. Myasthenia, orbital muscle entrapment, convergence spasm, divergence palsy, and pretectal pseudoconvergence entered into the differential diagnosis, but were only occasionally difficult to exclude.     

Functional neuroimaging in the preoperative evaluation of children with drug-resistant epilepsy

Functional neuroimaging Although the primary imaging modality in the management of epilepsy is magnetic resonance imaging MRI, functional neuroimaging with positron-emission tomography (PET) and single photon emission computed tomography (SPECT) often provides complementary information and, in a number of situations, provides unique information that cannot be obtained with MRI. The most commonly used PET tracers used for epilepsy evaluation are 2-deoxy-2-[¹⁸F]fluoro-d-glucose (FDG) and [¹¹C]flumazenil (FMZ). Recently, interictal PET with alpha-[¹¹C]methyl-l-tryptophan was found to be highly specific for the epileptic focus and can differentiate between epileptogenic and nonepileptogenic lesions in the same patient (e.g., in patients with tuberous sclerosis).Discussion In this review, we discuss clinical applications of these three PET tracers in drug-resistant temporal and extratemporal lobe epilepsy, selected epilepsy syndromes of childhood, lesional and nonlesional epilepsy, and the challenges of imaging secondary epileptic foci. A brief discussion of SPECT applications in epilepsy is also included. With further development of new tracers highly sensitive and specific for epileptogenic brain regions, the presurgical evaluation of refractory epilepsy will be greatly facilitated. Approximately 0.5 to 1.0% of the population suffer from epilepsy, of which 15–20% are intractable. Infants and children, whose seizures have a focal onset are refractory to anticonvulsants and are prolonged, tend to have the worst cognitive outcome [Meador KJ, Neurology 58 (Suppl 5):S21–S26, 2002]. Seizures themselves affect the developing brain and contribute to an adverse neurologic outcome (Holmes, Pediatric Neurology 33:1–110, 2005).Conclusion Therefore, in treating children with intractable epilepsy, it is important to consider seizure control and to give allowance for normal cognitive development.     

动态脑电图在脑瘫患儿诊断中的作用

目的 探讨动态脑电图(AEEG)在脑瘫患儿诊断中的作用. 方法 使用MB-8000型8道AEEG仪对我院2004-05~2008-05住院的128例脑瘫患儿进行监测.结果 本组128例中正常44例(34.4 %),异常84例(65.6 %).AEEG异常率相比,χ2= 8.38,P＜0.01. 结论 脑电图为无创伤性了解脑部损害的神经电生理检查方法,动态脑电图为脑瘫早期诊断提供重要依据,脑瘫患儿应普查脑电图,了解患儿脑细胞的功能状态,尤其早期发现样放电,预防二次脑损害有重要价值,是预后判断和指导治疗不可缺少的检查手段.     

Neurophysiologic and neuroimaging studies of brain plasticity in children with spastic cerebral palsy

Patients with cerebral palsy (CP) may have some problems other than this motor impairment: mental retardation, epilepsy and sensory disturbance. Healthy children and children with CP have an enhanced capacity for learning and memory compared to adults. There are few tools for brain plasticity investigations. The utility of the neurophysiologic and MRI techniques in the determination of brain reorganization and repair in patients with cerebral palsy is described. The authors discuss their results of quantitative EEG and spectroscopy MRI studies in children with CP. Quantitative EEG and spectroscopy MRI can be useful tools in the determination of these processes in children with CP.     

Hemangioma of the mandibular branch of the trigeminal nerve in the Meckel cave presenting with facial pain and sixth nerve palsy.

In a 25-year-old woman with episodic periorbital-temporal pain who eventually developed a sixth nerve palsy, magnetic resonance imaging revealed a lesion predominantly in the Meckel cave that was found to be a capillary hemangioma arising from the mandibular division of the trigeminal nerve. Hemangiomas of the Meckel cave must be considered in cases of facial pain with a sixth nerve palsy. even if there are no clinical findings of trigeminal neuropathy.     

Isolated sixth nerve palsy: an uncommon presenting sign of multiple sclerosis

We describe three patients in whom an isolated sixth nerve palsy was the only clinical symptom or sign of multiple sclerosis (MS). Data were collected prospectively over 6 years on these three patients, who showe no other signs of brainstem dysfunction or prior symptoms; in addition. Retrospective analysis of all patients with MS and all patients with sixth nerve palsy referred to a neuro-ophthalmology service between 1982 and 1998 showed isolated sixth nerve palsy to be the presenting sign of MS in only 0.5% of these patients. MS was the cause of isolated sixth nerve palsy in 0.8% of all patients and in 1.6% of those aged 18–50 years. Although it has been previously suggested that sixth nerve palsy is an ot uncommon presenting sign of MS, our results suggest it is rare. Received: 15 November 1999/Received in revised form: 15 March 2000/Accepted: 26 April 2000     

Isolated sixth nerve palsy due to intracavernous carotid aneurysm in a young woman

A large intracavernous carotid aneurysm was angiographically demonstrated in a 29 years old woman suffering from a persistent isolated abducens nerve palsy. CT brain scan failed to reveal the lesion. The usefulness of performing angiography in the cases of isolated abducens palsy of undetermined nature, is stressed.     

Tuberculous meningitis with initial manifestation of isolated oculomotor nerve palsy

Tuberculous meningitis (TB meningitis) is a subacute meningitis known for its various form of initial manifestations, which often make early diagnosis difficult. The present case report demonstrates a patient with TB meningitis, who had initial manifestation of isolated right oculomotor nerve palsy. High vigilance is needed in diagnosing TB meningitis. A 75 year-old female was hospitalized due to acute onset of right side ptosis. Thorough neurological examination at admission revealed isolated right oculomotor nerve palsy. Brain magnetic resonance imaging and cerebral angiography showed no specific finding. Lumbar puncture was performed two days later due to low grade fever. Cerebrospinal fluid (CSF) study and the polymerase chain reaction on CSF confirmed the diagnosis of TB meningitis. Because TB meningitis is a chronic disease, cranial nerve palsies are common manifestations. This report suggests that TB meningitis should be a disease of differential diagnosis for isolated oculomotor nerve palsy.     

Long-term outcome in children with congenital unilateral facial nerve palsy

During a 20-year period (1980 - 1999) 12 children with isolated congenital unilateral facial nerve palsy were seen at our hospital. The only child delivered by forceps made a full recovery from his palsy within two months, whereas functional improvement in patients with non-traumatic delivery was generally poor. In two patients the palsy affected predominantly the upper periocular region. In 10 children the lower facial region seemed to be mainly involved. Cognitive outcome was within normal limits, with one exception. Conventional neuroimaging was not contributory to the understanding of the pathogenetic mechanisms. We conclude that the majority of congenital unilateral facial nerve palsies are not of traumatic origin and carry a poor functional prognosis.     

Value of neuroimaging in the evaluation of neurologically normal children with recurrent headache

Headache is one of the most frequent physical complaints in children. Although headaches in children are generally benign, neuroimaging studies are frequently performed in clinical practice for the fear of missing a serious underlying disease. Despite this, limited data exist about the utility of neuroimaging in recurrent headache of children with a normal neurologic examination. This prospective study was planned to determine the value of neuroimaging in neurologically normal children with migraine and tension-type headache. Among 95 consecutive patients presenting with headache, 72 patients receiving a diagnosis of migraine or tension-type headache were included in the study. Neuroimaging procedures were performed in 83%. Magnetic resonance imaging (MRI) was abnormal in 11 of 49 cases. Abnormalities consisted of foci of gliosis in four, sinusitis in two, pineal cyst in one, periventricular leukomalacia in one, arachnoid cyst in one, old traumatic changes in one, and cervical syrinx in one. Two of the 11 computed tomographic (CT) scans revealed sinus disease. The percentage of findings causally related to headache was about 10. None of the patients had undergone surgery because of neuroimaging results. In conclusion, the yield of neuroimaging in recurrent headaches of children with a normal neurologic examination is low, and neuroimaging should not be part of a routine initial examination of these patients.     

Early reversible leukoencephalopathy and unilateral sixth cranial nerve palsy in mild COVID-19 infection

Neurological Sciences - To provide new insights into neurological manifestations of COVID-19. We describe a patient with mild COVID-19 associated with diplopia from right sixth cranial nerve palsy...