One-Sided Headache Is a Symptom Suggesting Aneurysmal Lesion in Patients with Isolated Abducens Nerve Palsy

An isolated unilateral abducens nerve palsy or headache alone usually yields negative findings on neuroimages. The authors report an individual with right abducens nerve palsy who developed a sudden, persistent headache on the right side. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) revealed a giant aneurysm of the cavernous carotid artery that was located along the course of the right abducens nerve. The findings in this case of isolated abducens nerve palsy suggest that headaches should be considered as important signs for intracranial aneurysmal lesions.     

A Prospective Study of the Causes and Magnetic Resonance Imaging Findings in Adult Isolated Non-traumatic Unilateral Abducens Palsy in Taiwan

The objective of this study was to investigate the causes of acute isolated non-traumatic unilateral abducens palsy in adults and to evaluate the diagnostic relevance of Magnetic Resonance Imaging (MRI). This prospective study included a total of 40 patients presenting with acute isolated unilateral non-traumatic abducens palsy from January 2002 to June 2008 at Buddhst Tzu Chi General Hospital, Hualien. A standardized MRI protocol was performed within 1 week of the patient's first visit. In 23 patients (57.5%) a lesion was identified on the initial MRI relevant to the sixth nerve palsy. In 8 patients (20%) the cause was nasopharyngeal carcinoma. The MRI was positive in 4 out of 15 diabetic patients, and in 5 out of 12 patients with hypertension. MRI demonstrated the aetiology in 57.5% of cases of acute isolated non-traumatic unilateral abducens palsy, with nasopharyngeal carcinoma being a common cause in our study. We suggest a complete MRI study of the brain and the orbits, with axial, coronal and sagittal imaging, the use of intravenous contrast, and fat suppression techniques in acute adult isolated non-traumatic unilateral abducens palsy.     

Functional and Motor Outcomes of Strabismus Surgery for Chronic Isolated Adult Sixth Nerve Palsy

Abstract

Abducens nerve palsy is the most common acquired ocular motor nerve palsy in adults. Chronic cases of abducens palsy often require surgical intervention to relieve disabling diplopia. The goal of this study was to identify factors associated with surgical outcomes in isolated abducens palsy. Medical records of all adult patients from 1988 to 2012 with abducens palsies who underwent strabismus procedures were retrospectively reviewed. Motor alignment, extraocular motility, and sensory outcomes were recorded. Success was defined as absence of diplopia without prisms or face turn, vertical deviation ≤2 prism dioptres (PD), and horizontal deviation ≤10 PD. Eighty-one patients (age range: 20–86 years) met inclusion criteria. Success was achieved in 58% of patients. Final success rates for abducens palsy were 50% for neoplastic, 59% traumatic, 57% for microvascular/unknown, and 67% for other central nervous system causes (p?>?0.05). Patients with an underlying neoplastic or traumatic aetiology required more than one strabismus procedure more often than those with microvascular/idiopathic or other central nervous system causes (48% vs. 24%; p?=?0.03). For complete abducens palsies, patients who underwent Hummelsheim-type procedures had a higher success rate than those who underwent a full-tendon vertical rectus muscle transposition. (78% versus 35%; p?=?0.049). Success rates for strabismus procedures in patients with abducens palsies are similar across all aetiologies. Frequency of re-operation is higher among those patients with neoplastic or traumatic aetiologies for their abducens palsies. Hummelsheim-type procedures have a higher success rate for complete abducens palsies than full-tendon vertical rectus transpositions.     

Functional and Motor Outcomes of Strabismus Surgery for Chronic Isolated Adult Sixth Nerve Palsy

Abducens nerve palsy is the most common acquired ocular motor nerve palsy in adults. Chronic cases of abducens palsy often require surgical intervention to relieve disabling diplopia. The goal of this study was to identify factors associated with surgical outcomes in isolated abducens palsy. Medical records of all adult patients from 1988 to 2012 with abducens palsies who underwent strabismus procedures were retrospectively reviewed. Motor alignment, extraocular motility, and sensory outcomes were recorded. Success was defined as absence of diplopia without prisms or face turn, vertical deviation ≤2 prism dioptres (PD), and horizontal deviation ≤10 PD. Eighty-one patients (age range: 20–86 years) met inclusion criteria. Success was achieved in 58% of patients. Final success rates for abducens palsy were 50% for neoplastic, 59% traumatic, 57% for microvascular/unknown, and 67% for other central nervous system causes (p > 0.05). Patients with an underlying neoplastic or traumatic aetiology required more than one strabismus procedure more often than those with microvascular/idiopathic or other central nervous system causes (48% vs. 24%; p = 0.03). For complete abducens palsies, patients who underwent Hummelsheim-type procedures had a higher success rate than those who underwent a full-tendon vertical rectus muscle transposition. (78% versus 35%; p = 0.049). Success rates for strabismus procedures in patients with abducens palsies are similar across all aetiologies. Frequency of re-operation is higher among those patients with neoplastic or traumatic aetiologies for their abducens palsies. Hummelsheim-type procedures have a higher success rate for complete abducens palsies than full-tendon vertical rectus transpositions.     

后天性外展神经麻痹的MRI病因学分析

 目的 探讨后天性外展神经麻痹的MRI表现,分析外展神经麻痹原因,为临床诊断、治疗提供依据。设计 回顾性病例系列。研究对象 42例后天性外展神经麻痹患者。方法 回顾性分析42例临床诊断证实的后天性外展神经麻痹患者的MRI表现,包括病变部位、范围、信号和强化特征,结合外展神经的解剖特点,分析神经麻痹的原因。主要指标 MRI表现。结果 缺血性外展神经麻痹16例,患者均有糖尿病、高血压或高脂血症等病史,MRI表现为颅内多发缺血灶、软化灶,老年性脑萎缩等。占位性病变15例,病变位于桥前池、岩尖和海绵窦,累及展神经脑池段、Dorello小管段和海绵窦段。外伤性外展神经麻痹5例,1例有右侧颅骨多发骨折,出现左侧外展神经麻痹症状,其余4例均无明确颅骨和眼眶骨折证据。非特异性炎症4例,3例表现为海绵窦偏前部增厚、强化。其他原因包括重症肌无力1例,桥小脑角区胆脂瘤术后1例。结论 MRI检查有助于明确外展神经麻痹的病因及发病部位,进而指导针对性治疗。（眼科,2013, 22： 305-308）     

头颅外伤患者的眼运动神经麻痹(英文)

目的:了解头颅外伤患者眼运动神经麻痹的情况。方法:收集2006-03/2006-09 Shahid Rahnemon医院神经外科收治的300名头颅外伤患者的资料,包括眼科检查和调查问答,采用SPSS软件卡方和F检验进行数据分析。结果:300例患者中242例为男性(81. 1% ), 58例为女性(18.9% ),年龄为1~87(平均46)岁。意外跌伤是头部外伤最常见的原因,共247例患者(82. 3% )因此致伤;大多数患者的GCS得分为13~15(82.3% )。最多见的颅脑外伤为硬膜下腔、蛛网膜下腔出血。滑车神经或外展神经麻痹(28.6% )、其他眼运动神经麻痹或同时两处眼运动神经麻痹(常见第3颅神经和第4颅神经麻痹,14.3% )是最常出现的情况。结论:虽然头颅外伤同时出现颅神经麻痹的几率较小,但是在急诊时应根据情况进行神经眼科检查。     

Abducens Palsy and Anosmia Associated with COVID-19: A Case Report

Aim:To report the case of acute isolated abducens nerve palsy and anosmia in a healthy 69-year-old female following SARS-CoV-2 infection.Method:This is a case report of a previously healthy 69-year-old Caucasian female who presented to the emergency eye centre with a four-day history of binocular, horizontal diplopia eight days after testing positive for SARS-CoV-2 infection. Anosmia was her isolated symptom of COVID-19.Results:The patient was diagnosed with left abducens nerve palsy. Aetiology was presumed to be post-viral as the patient was not diabetic and had no pre-existing microvascular risk factors. Diplopia resolved within 3.5 weeks. Measurements confirmed complete spontaneous recovery of the abducens palsy within 6 weeks.Conclusion:Cranial nerve palsies may constitute part of the neurological spectrum of COVID-19 disease. This case report aims to raise awareness amongst clinicians of coronavirus-induced neurological symptoms. Research suggests SARS-CoV-2 infection can trigger an aberrant immune response in some individuals, causing inflammatory nerve damage leading to anosmia and neuropathy. This case report supports the hypothesis that direct or indirect virally mediated injuries along the routes of the cranial nerves can cause neuropathy and olfactory dysfunction. The longer latency effects of COVID-19 infection are not well understood. The long-term rehabilitation of patients exposed to COVID-19 is a major public health concern requiring multidisciplinary expertise. This case report highlights the value of the Orthoptist in the diagnosis and care of patients experiencing neuropathy following COVID-19 exposure.     

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.     

Presumed Metastasis of Breast Cancer to the Abducens Nucleus Presenting as Gaze Palsy

A 51-year-old woman with breast cancer presented with progressive diplopia. Neuro-ophthalmologic examination revealed right gaze palsy and peripheral facial nerve palsy. Brain magnetic resonance imaging (MRI) was normal. However, two months later a repeat brain MRI revealed an enhancing round nodular mass at the right facial colliculus of the lower pons, at the location of the abducens nucleus. Localized metastasis to the abducens nucleus can cause gaze palsy in a patient with breast cancer.     

Neurological Imaging in Acquired Cranial Nerve Palsy: Ophthalmologists vs. Neurologists

ABSTRACT

Purpose: Cranial nerve palsies often require neurological imaging by MRI. Guidelines on whether or not to utilize MRI have been absent or lack clarity. In daily practice, both neurologists and ophthalmologists treat patients with cranial nerve palsy and determine whether neuro-imaging is required. There appear to be differences in policy with respect to neuro-imaging. The question, which will be answered in this study, is the following: to what extent do differences in policy exist between ophthalmologists and neurologists regarding imaging by MRI of patients with acquired ocular cranial nerve palsy?

Method: PubMed database was searched for literature on acquired cranial nerve palsy and MRI scanning performed by ophthalmologists and neurologists. Case series published between 2000 and 2015 were included. The first author screened the literature on eligibility, profession of the authors, and conducted data abstraction.

Result: Ten case series were found eligible for analysis. A total of 889 cranial nerve palsies were described, 770 by ophthalmologists and 119 by neurologists. The age range of patients in all case series was 2 to 96 years of age. The oculomotor nerve was investigated in 162 patients, the trochlear nerve in 131 patients, and the abducens nerve in 486 patients. All neurologists (n=3) and 2 out of 7 investigated ophthalmologists recommended performing MRI scanning in every patient who presented with an ocular cranial nerve palsy, while 5 ophthalmologists (5/7) opted to triage patients for risk factors associated with cranial nerve palsies prior to ordering MRI imaging. When different groups of patients were viewed separately, it became apparent that almost all specialists agreed that every patient with a third nerve palsy and patients under 50 years of age should undergo MRI scanning. In patients with fourth nerve palsy, MRI scanning was not indicated.

Conclusion: The neurologists in this study were more likely to perform MRI scanning in every patient presenting with ocular cranial nerve palsy. Ophthalmologists were more likely to determine risk factors associated with cranial nerve palsy, which they took into account when deciding whether or not to perform neurological imaging in patients aged more than 50 years or presenting with abducens nerve palsy.     

Late-Onset Abducens Nerve Palsy after Endovascular Treatment for Carotid-Cavernous Fistula: Two Case Reports

Endovascular treatment, including transarterial embolisation and transvenous embolisation, is generally considered effective for treating carotid-cavernous fistula. Immediate cranial nerve palsy following the procedure is the most common complication, but it usually resolves spontaneously. The authors report two cases of late-onset abducens nerve palsy after successful obliteration of direct carotid-cavernous fistulas, both of which required strabismus surgery.     

Acute abducens nerve palsy after COVID-19 vaccination in a young adult

We present the case of a 23-year-old young man with left-eye abducens nerve palsy following the COVID-19 vaccination. Given the temporal relationship between vaccination and the onset of symptoms, the lack of systemic history, and unremarkable magnetic resonance imaging, the patient’s abducens nerve palsy was related to his vaccination. The ophthalmologist should be aware of this neurotropic sequela of COVID-19 vaccination in young adults.     

Abstracts of the 2010 Meeting of the International Neuro-Ophthalmology Society,Lyon, France

Abstract

Endovascular treatment, including transarterial embolisation and transvenous embolisation, is generally considered effective for treating carotid-cavernous fistula. Immediate cranial nerve palsy following the procedure is the most common complication, but it usually resolves spontaneously. The authors report two cases of late-onset abducens nerve palsy after successful obliteration of direct carotid-cavernous fistulas, both of which required strabismus surgery.     

Isolated trochlear nerve palsy with midbrain hemorrhage

Midbrain hemorrhage causing isolated fourth nerve palsy is extremely rare. Idiopathic, traumatic and congenital abnormalities are the most common causes of fourth nerve palsy. We report acute isolated fourth nerve palsy in an 18-year-old lady due to a midbrain hemorrhage probably due to a midbrain cavernoma. The case highlights the need for neuroimaging in selected cases of isolated trochlear nerve palsy.     

The diagnostic yield of neuroimaging in sixth nerve palsy - Sankara Nethralaya Abducens Palsy Study (SNAPS): Report 1

Aims:The aim was to assess the etiology of sixth nerve palsy and on the basis of our data, to formulate a diagnostic algorithm for the management in sixth nerve palsy.Design:Retrospective chart review.Results:Of the 104 neurologically isolated cases, 9 cases were attributable to trauma, and 95 (86.36%) cases were classified as nontraumatic, neurologically isolated cases. Of the 95 nontraumatic, isolated cases of sixth nerve palsy, 52 cases were associated with vasculopathic risk factors, namely diabetes and hypertension and were classified as vasculopathic sixth nerve palsy (54.7%), and those with a history of sixth nerve palsy from birth (6 cases) were classified as congenital sixth nerve palsy (6.3%). Of the rest, neuroimaging alone yielded a cause in 18 of the 37 cases (48.64%). Of the other 19 cases where neuroimaging did not yield a cause, 6 cases were attributed to preceding history of infection (3 upper respiratory tract infection and 3 viral illnesses), 2 cases of sixth nerve palsy were found to be a false localizing sign in idiopathic intracranial hypertension and in 11 cases, the cause was undetermined. In these idiopathic cases of isolated sixth nerve palsy, neuroimaging yielded no positive findings.Conclusions:In the absence of risk factors, a suggestive history, or positive laboratory and clinical findings, neuroimaging can serve as a useful diagnostic tool in identifying the exact cause of sixth nerve palsy. Furthermore, we recommend an algorithm to assess the need for neuroimaging in sixth nerve palsy.     

Pupil sparing incomplete third nerve palsy secondary to a cavernous sinus meningioma: challenges in management

Background: The diagnosis of incomplete third nerve palsy can be clinically challenging because the aetiologies, as well as presentations, can be variable and subtle. The optometric clinician should be familiar with the association of third nerve palsy with compressive lesions, including the clinical presentations and management of these patients. Case report: We present a 68‐year‐old hypertensive male complaining of intermittent diplopia for the previous six months. Neurological examination revealed a mild deficit in adduction, reduced range of vertical motility and questionable ptosis, all limited to the OD. No pupillary involvement was noted. MRI revealed a cavernous sinus meningioma. The patient elected against surgery, choosing MRI every six months. Conclusion: Due to the subtle clinical presentation of incomplete pupil sparing third nerve palsy, this ophthalmoplegia may be easily overlooked. The associated aetiologies of palsy of cranial nerve three (CN3) carry increased risk of morbidity and mortality. Management should include evaluation for mass lesions and/or vascular aetiologies, regardless of pupillary involvement.     

Isolated Fourth Nerve Palsy in Tuberculous Meningitis

Tuberculous meningitis is a type of subacute meningitis and like other intracranial processes can compromise ocular motor nerves, causing palsies. Trochlear nerve is an unusual isolated manifestation in this type of pathology. The authors report a 5-year-old boy presented in their clinic with a trochlear nerve palsy as unique neurological manifestation of tuberculous meningitis. Treatment with complete anti-tuberculous therapy and botulinum A toxin was needed to get the complete resolution of the nerve palsy. In tuberculous meningitis, the presence of high protein levels and higher number of cells in cerebrospinal fluid is associated with cranial nerve involvement. Usually cranial nerve palsies occur in combination. VI cranial nerve alone or a combined disorder of VI and III cranial nerves are the palsies most frequently presented. Much less common is an isolated disorder of IV cranial nerve in the course of meningitis. The length of full treatment with anti-tuberculous therapy in this case was of 1 year. The persistence of palsy 1 month after the beginning of the symptoms indicated the possibility of a botulinum toxin injection with complete resolution of the process without disability, ocular motility has remained normal on follow-up.     

First a third, then a fourth nerve palsy in multiple intracranial aneurysms

Background Intracranial aneurysms may be a cause of ocular motor dysfunction, the third nerve being more often involved than the two other cranial ocular motor nerves. Methods We report the unusual occurrence of an isolated fourth nerve palsy related to a cavernous carotid aneurysm, angiographically confirmed. The patient already underwent clipping of a ruptured posterior communicating artery aneurysm 17 years earlier, revealed at that time by a third nerve palsy. Results Endovascular treatment of the cavernous carotid aneurysm was performed, resulting in complete recovery of the palsy. Conclusion Occurrence of an acquired fourth nerve palsy in a patient with a past history of aneurysm should prompt neurovascular imaging as multiple aneurysms may cause sequential ocular motor palsies.     

Pituitary Adenoma Manifesting as an Isolated Abducens Palsy

Ocular motor nerve palsies are rare complications of pituitary adenoma. We treated a patient who presented with an isolated abducens palsy and was subsequently found to have a pituitary adenoma. A 62-year-old woman was referred to us for an evaluation of her diplopia. She had an esotropia, which was larger on right gaze, and a limited abduction OD. Visual fields were normal. CT and MRI revealed a sellar region tumor invading the right cavernous sinus without compressing the optic chiasm. A diagnosis of macroprolactinoma was made endocrinologically. Her diplopia and right abducens palsy were quickly resolved and MRI showed significant shrinkage of the tumor after she was treated with cabergoline. A sixth nerve palsy can be the sole presenting feature of pituitary adenoma and can be treated effectively with medication.     

Pediatric ocular motor cranial nerve palsy: Demographics and etiological profile

Purpose:The aim of this study was to describe epidemiological and clinical characteristics of pediatric ocular motor cranial nerve palsy.Methods:This was a retrospective record-based study, carried out at a tertiary eye care hospital in India, between January 2011 and January 2015 and included patients up to 16 years of age at the time of presentation, diagnosed with third, fourth, sixth nerve palsy or a combination of these with other cranial nerve palsy. Data analyzed included demographic details, etiologies, presence or absence of amblyopia, relevant investigations, and management.Results:A total of 90 cases were included in the study. Eighty patients (88.88%) presented with isolated nerve palsy. Forty-three patients (47.77%) had congenital nerve palsy. The most common nerve involved was third (n = 35, 38.88%) followed by sixth (n = 23, 25.55%) and fourth nerve (n = 22, 24.44%). Most common cause of third and fourth cranial nerve palsy was congenital (n = 18, 51.42% and n = 17, 77.30%, respectively), while it was trauma for the sixth nerve (n = 7, 30.40%). Amblyopia was most frequently associated with third cranial nerve palsy (n = 27, 77.14%). The radio-imaging yield was maximum (n = 7, 70%) for combined cranial nerve palsy. Overall 44 (48.88%) patients were managed conservatively, while 46 (51.11%) patients needed squint with or without ptosis surgery.Conclusion:The most common ocular motor cranial nerve involved in the pediatric population was the third cranial nerve, and it was found to be the most amblyogenic in this age group. The neuroimaging yield was maximum for combined cranial nerve palsy. The most common conservatively managed nerve palsy in this study group was the fourth nerve palsy.