The effect of ultrasound guided superior cervical sympathetic ganglion block to abducens nerve palsy caused by microvascular ischemia-a case report

Abstract

The abducens nerve palsy is most likely caused by microvascular issue. Spontaneous recovery of vasculopathic abducens nerve palsies was common at 3 to 6 months. But recovery time was longer when many risk factors were present. Several patients had residual esotropia or abduction deficit. Cervical sympathetic block has an established use in treating patients with disorders related to cranial circulatory insufficiency. It causes a significant increase in cerebral blood flow 1,2. We report a case of a 67-year-old man with acute horizontal diplopia and right periocular pain. He had been diagnosed with right abducens nerve palsy caused by microvascular ischemia. We performed ultrasound-guided superior cervical sympathetic ganglion blocks. The patient was placed in a supine position, and his head was turned approximately 45 degrees to the left side. A transducer was transversely oriented over the right side of his neck, and the transverse process of C6 was located to the cricoid cartilage level. The transducer was moved in the cephalad direction along the neck to locate the common carotid bifurcation. After identifying the oval-shaped and hypoechoic structure between the longus capitis muscle and the starting point to branch off the common carotid bifurcation, a 23-gauge needle was introduced slowly from a lateral approach with the in-plane technique using ultrasound guidance. The needle was inserted until it approached the target site, and it was positioned immediately adjacent to the structure appearing to be the SCSG. We performed the SCSG block with 5 cc of 0.2 % ropivacaine, and then we identified Horner's sign on the same side after the injection. He received blocks in the same manner once every three or four days due. After four weeks, the symptoms had been completely resolved. We introduce ultrasound-guided superior cervical sympathetic ganglion blocks for management of abducens nerve palsy caused by microvascular ischemia, which could be an effective novel method to promote recovery from diplopia. We think that the recovery of ischemic demyelination of a portion of the nerve is greatly assisted by an improvement in the cerebral blood flow.