Sixth Nerve Palsy Research Articles

Acute abducens nerve palsy following coronavirus disease 2019 vaccination: a case report

BackgroundAbducens nerve palsy is the most common isolated ocular cranial nerve palsy. In adults, nontraumatic etiologies of isolated sixth cranial nerve palsy can include vascular disease, inflammation, tumors, and a prior history of infection.Case presentationWe present a case of a 52-year-old Asian male who developed acute abducens nerve palsy after vaccination with the AstraZeneca coronavirus disease 2019 vaccine. A complete workup including magnetic resonance imaging of the brain and orbits revealed no abnormalities. The patient experienced a gradual recovery over 10 weeks through alternative eye patching. The abducens nerve palsy is postulated to be correlated with the coronavirus disease 2019 vaccine.ConclusionDespite the recognized efficacy and cost benefits of coronavirus disease 2019 vaccines, clinicians should be aware of the possible association between cranial nerve palsies and coronavirus disease 2019 vaccines.

Transsylvian transopercular peri-central core hemispherotomy for treating epilepsy: anatomy, surgical technique, and clinical outcome.

The objective of this study was to display the anatomical landmarks, surgical technique, and clinical outcome of transsylvian transopercular peri-central core hemispherotomy (TTPH) for treating refractory epilepsy. From 2011 to 2023, 26 patients (12 with Rasmussen syndrome, 8 with hemimegalencephaly/cortical malformations, and 6 with hypoxic-ischemic encephalopathy; mean [range] age 11.3 years [16 months to 35 years]; 13 females; and 13 with right-side pathology) underwent TTPH. The mean (range) follow-up was 88 (14-156) months. The intradural surgical time, use and amount of blood transfusion, postoperative fever, hospital stay, weight at surgery, and seizure onset to surgery interval are reported. TTPH consists of 1) sylvian fissure opening, 2) coagulation of the M2 and M3 branches, 3) frontoparietal opercula removal, 4) suprainsular resection, 5) insula removal, 6) selective amygdalohippocampectomy, 7) disconnection of the posterior temporal and occipital lobes using the tentorium and falx as landmarks, 8) intraventricular callosotomy, and 9) disconnection of the basal frontal lobe. In cortical malformation, the gray-white matter interface serves as a landmark. The average intradural operating time was 7 hours 18 minutes (3 hours 33 minutes to 13 hours 45 minutes); all patients were Engel class I; and 2 patients presented with procedure-related complications (meningitis and transient abducens nerve palsy). No patient required shunt surgery or reoperation. TTPH offers anatomical landmarks as intraoperative guides and has achieved good seizure control and low complication rates.

Neurosyphilis patients presenting with ocular motor cranial nerve palsy in the modern antibiotic era: Case series from two centers and review of the literature

BackgroundSyphilis can mimic the clinical features of many neurological disorders and cause ocular motor cranial nerve palsy (OMCNP). This study aims to characterize the clinical features of neurosyphilis patients presenting with OMCNP. Methods In a retrospective study and literature review, demographic data, clinical presentations, laboratory findings, radiological findings, treatment approaches, and outcomes were recorded and analyzed. ResultsOverall, 0.74 % and 1.64 % of patients presenting to two institutes exhibited syphilitic OMCNP, respectively. A total of 32 patients (23 from the literature) were recruited, with a median age of 46 years and a predominance of males (81.3 %). Meningovascular neurosyphilis was diagnosed in 29 patients (90.6 %), and tabes dorsalis was found in 3 patients (9.4 %). Unilateral OMCNP was present in 24 patients (65.5 %). Unilateral sixth nerve palsy was observed in 10 patients (34.5 %), followed by unilateral third nerve palsy in 9 patients (31.0 %), and unilateral multiple OMCNP in 5 patients (17.2 %). A total of 12 patients (41.4 %) presented with isolated OMCNP, and 4 of these individuals developed other neurological deficits during the disease. Pupillary involvement was found in all patients who presented unilateral third nerve palsies. After treatment, 17 patients (58.6 %) achieved complete recovery of ocular motility; 6 patients (20.7 %) achieved partial recovery; 5 patients (17.2 %) remained stable; and 1 patient (3.5 %) became progressive. ConclusionsPatients presenting with OMCNP alone or combined with other cranial nerve deficits should be screened for neurosyphilis, and the standard treatment regimen should be initiated if a diagnosis of neurosyphilis is established.

Exploring the Impact of Genetics in a Large Cohort of Moebius Patients by Trio Whole Exome Sequencing.

Moebius syndrome (MBS) is a rare congenital disorder characterized by non-progressive facial palsy and ocular abduction paralysis. Most cases are sporadic, but also rare familial cases with autosomal dominant transmission and incomplete penetrance/variable expressivity have been described. The genetic etiology of MBS is still unclear: de novo pathogenic variants in REV3L and PLXND1 are reported in only a minority of cases, suggesting the involvement of additional causative genes. With the aim to uncover the molecular causative defect and identify a potential genetic basis of this condition, we performed trio-WES on a cohort of 37 MBS and MBS-like patients. No de novo variants emerged in REV3L and PLXND1. We then proceeded with a cohort analysis to identify possible common causative genes among all patients and a trio-based analysis using an in silico panel of candidate genes. However, identified variants emerging from both approaches were considered unlikely to be causative of MBS, mainly due to the lack of clinical overlap. In conclusion, despite this large cohort, WES failed to identify mutations possibly associated with MBS, further supporting the heterogeneity of this syndrome, and suggesting the need for integrated omics approaches to identify the molecular causes underlying MBS development.

Surgical outcome of endoscopic endonasal approach as a modality of management for large and giant pituitary adenomas: a retrospective case series

BackgroundLarge and giant pituitary adenomas (defined as tumors of maximal diameter ≥ 3–3.9 cm and ≥ 4 cm, respectively) present considerable surgical challenges regarding the extent of resection and perioperative morbidity. Endoscopic endonasal resection is considered the most effective treatment for pituitary adenomas. It allows for better visualization, maneuverability, and access to distant and lateral tumor compartments, ultimately enhancing the extent of resection. This article evaluates our initial experience with endoscopic endonasal resection of large and giant pituitary adenomas. The clinical outcomes, perioperative complications, and extent of tumor resection would be specifically addressed.Patients and methodsThe primary goal of surgery was to decompress the optic pathways, and the secondary goals were to achieve maximal safe resection and hormonal control in hormone-secreting adenomas. The degree of tumor resection was classified as gross-total resection (100%), near-total resection (90–100%), subtotal resection (70–90%), and partial resection (< 70%).Results42 patients were included in this study. A good visual outcome achieved with 80% improvement in visual symptoms. Gross-total resection (GTR) was achieved in 19 patients (45.2%), near-total resection (NTR) was achieved in 12 patients (28.6%), subtotal resection (STR) in 6 patients (14.3%), and partial resection in the remaining 5 patients (11.9%). Subgroup analysis revealed that GTR, NTR rates were higher in large, compared to giant tumors. GTR, NTR rates of large adenomas were 59.3%, and 29.6%, compared to 20%, and 26.7% in giant adenomas respectively (p-value: 0.01428). Surgical complications were observed in 19 patients (45.2%) with CSF leakage being the most common complication (11 patients, 26.2%). Post-operative diabetes insipidus was observed in 5 patients (11.9%), major vascular injury in one case (2.4%), transient post-op 6th nerve palsy observed in 3 patients (7.1%), while two patients (4.8%) presented with post-operative paranasal sinuses infection.ConclusionsEndoscopic endonasal transsphenoidal resection of large and giant pituitary adenomas is a safe and efficient procedure. Large adenomas (3–3.9 cm) have excellent resection rates and lower complications than giant adenomas (≥ 4 cm), which may require extending our approach to achieve more tumor resection rates in the future. However, only adequate resection of these giant adenomas can be enough to achieve the main surgical goals of visual improvement, hormonal control, and decompression of surrounding structures.

Outcomes and Factors Associated with Successful Strabismus Surgery for Abducens Nerve Palsies: A Retrospective Study and Literature Review.

Several studies reported surgical outcomes for abducens nerve palsy, but information on factors that affect treatment success remains lacking. These factors are crucial for developing a treatment plan and providing disease counseling. This study aimed to investigate the outcomes of strabismus surgery for abducens nerve palsy and determine the factors that influence its success, including a review of relevant literature. This retrospective analysis included abducens nerve palsy cases, focusing on surgical interventions and relevant patient data, at the outpatient clinics of Phramongkutklao Hospital from April 1, 2012, to April 30, 2022. A relevant literature review included the surgical success rate and factors that influence surgical outcomes. This study enrolled 32 patients, including 19 with partial and 13 with complete abducens nerve palsy. The overall success rate of strabismus surgery was 78.1%. Trauma was the leading cause of abducens nerve palsy in this population (28.13%). Fisher's exact and Mann-Whitney U-tests revealed that shorter abducens nerve palsy onset and smaller preoperative angle were significantly associated with successful surgical outcomes of strabismus surgery among the groups. In contrast, subgroup analysis revealed that only preoperative smaller angles were significantly associated with good surgical outcomes in horizontal strabismus surgery. However, the vertical rectus muscle transposition group demonstrated no significant factors. The literature review revealed that the success rate of surgery in abducens nerve palsy was 25%-82.6% for horizontal rectus muscle surgery and 46.2%-91% for rectus muscle transposition. The surgical success rate for abducens nerve palsy reached 78.1%, including 78.95% for partial and 76.92% for complete abducens nerve palsy. Notably, a shorter onset preceding surgery and a smaller preoperative angle significantly correlated with successful surgical outcomes one year postoperatively.

Abducens nerve palsy in a young girl with otorrhea: A case of Gradenigo's syndrome

Abducens nerve palsy in a young girl with otorrhea: A case of Gradenigo's syndrome

Lateral rectus palsy as the first presentation of Kikuchi Fujimoto&amp;rsquo;s disease

Kikuchi Fujimoto’s Disease (KFD) or histiocytic necrotising lymphadenitis is recognised as a disease with a benign and indolent course. The common clinical symptoms of KFD include fever, headache, arthralgia and cervical lymphadenopathy. The diagnosis is based on clinical grounds and histological findings of lymph node biopsy. Kikuchi disease presenting with neurological manifestations is seldom seen. Out of all reported neurological manifestations, aseptic meningitis, brainstem encephalitis and cerebellar ataxia are common. We report a case of a 16 year old girl presenting with right sided lateral rectus palsy as the first presentation of KFD.

Clinical Features of Surgery Candidates for Different Types of Extraocular Muscle Palsy

Introduction: Clinical manifestations of cranial nerve palsies are of great importance, and surgeons should consider them before planning surgical protocol. Materials and Methods: This retrospective study was conducted on preoperative hospital records of 598 Iranian patients with different types of extraocular muscle palsy, including third (90 patients), fourth (501 patients), and fifth (7 patients) nerve palsy at Farabi Hospital, Tehran Province, Iran. Results: In terms of fourth nerve palsy, the mean spherical equivalent (SE) in the right and left eye was 0.23±1.51 and 0.19±1.45 diopter, respectively. Also, the mean angle of vertical deviation was 15.54±8.85 Δ at near and 15.66±8.93 Δ at far. In patients with third nerve palsy, the mean SE in the right and left eye was -0.02±2.08 and 0.08±1.95 diopter, respectively. Also, the mean angle of vertical deviation was 17.8±17.4 Δ at near and 17.8±17.5 Δ at far. In terms of six nerve palsy, the mean SE in the right and left eye was -1.27±3.37 and -1.08±2.52 diopter, respectively. Also, the mean angle of esotropia was 32.4±7.7 Δ at near and 33±6.7 Δ at far. The frequency of amblyopia in patients with third, fourth, and sixth nerve palsies was 21 patients (23.3%), 70(14%), and 4(57.1%), respectively. Conclusion: The clinical characteristics of patients with different types of EOM palsy are remarkably different, which can be attributed to the different properties of these kinds of deviations.

A deep learning-based image analysis for assessing the extent of abduction in abducens nerve palsy patients before and after strabismus surgery

PurposeThis study aimed to propose a novel deep learning-based approach to assess the extent of abduction in patients with abducens nerve palsy before and after strabismus surgery. MethodsThis study included 13 patients who were diagnosed with abducens nerve palsy and underwent strabismus surgery in a tertiary hospital. Photographs of primary, dextroversion and levoversion position were collected before and after strabismus surgery. The eye location and eye segmentation network were trained via recurrent residual convolutional neural networks with attention gate connection based on U-Net (R2AU-Net). Facial images of abducens nerve palsy patients were used as the test set and parameters were measured automatically based on the masked images. Absolute abduction also was measured manually, and relative abduction was calculated. Agreements between manual and automatic measurements, as well as repeated automatic measurements were analyzed. Preoperative and postoperative results were compared. ResultsThe intraclass correlation coefficients (ICCs) between manual and automatic measurements of absolute abduction ranged from 0.985 to 0.992 (P＜0.001), and the bias ranged from −0.25 ​mm to −0.05 ​mm. The ICCs between two repeated automatic measurements ranged from 0.994 to 0.997 (P＜0.001), and the bias ranged from −0.11 ​mm to 0.05 ​mm. After strabismus surgery, absolute abduction of affected eye increased from 2.18 ​± ​1.40 ​mm to 3.36 ​± ​1.93 ​mm (P＜0.05). The relative abduction was improved in 76.9% patients (10/13) after surgery (P＜0.01). ConclusionsThis image analysis technique demonstrated excellent accuracy and repeatability for automatic measurements of ocular abduction, which has promising application prospects in objectively assessing surgical outcomes in patients with abducens nerve palsy.

Age-Related Risk of Stroke Following Ocular Motor Cranial Nerve Palsy.

This cohort study aims to examine the relationship between the occurrence of cranial nerve palsy (CNP) affecting the third, fourth, or sixth cranial nerve and the subsequent risk of stroke, with a particular focus on the modulating effect of age on this association. We established a cohort of individuals diagnosed with third, fourth, or sixth CNP who underwent national health screening within 2 years of diagnosis from 2010 to 2017. A control group was matched by sex and age at a ratio of 1:5. Participants were followed until December 31, 2019. We use multivariable Cox proportional hazards regression analyses to assess the association between ocular motor CNP and subsequent stroke stratified by age. Covariates including lifestyle, health behavior, underlying comorbidities, and Charlson comorbidity index score were also adjusted. Compared with the control group, the ocular motor CNP group had a higher risk of stroke after adjusting for potential confounders (hazard ratio [HR], 1.23 [95% CI,, 1.08-1.39]). The risk of stroke increased by 8.91 times in individuals with ocular motor CNP who were in their 30s (HR, 8.91 [95% CI, 1.63-48.66]). The risk increased by 2.49 times in those who were in their 40s, 1.78 times in those who were in their 50s, and 1.32 times in those who were in their 60s (HRs, 2.49, 1.78, and 1.32 [95% CI, 1.39-4.45, 1.31-2.42, and 1.08-1.62], respectively). However, for those who were in their 20s, 70s, or 80s, the incidence of stroke did not significantly increase. Our study establishes an association between ocular motor CNP and an increased risk of stroke, particularly in young adults.

Approaching Saber-Sheath Trachea in a Patient with Bilateral Vocal Cord Abductor Palsy and Post Tracheostomy Tracheal Stenosis.

Human trachea has variable shapes and the most common are circular and oval-shaped. Other shapes are rare to find and usually related to some diseases. Such as the Saber-sheath shaped trachea, which was commonly attributed to patients with chronic obstructive pulmonary disease (COPD). This case is about a patient who was detected to have dual pathology, bilateral vocal cord abductor palsy, and post-tracheostomy complicated with tracheal stenosis for 40 years. Symptoms worsened in the last three years until he was admitted to the ward. However, upon managing this case with multilevel airway obstruction, we have found out that this patient who did not have COPD, has a Saber-sheath trachea shape. This finding may indicate that the shape is not limited to a certain disease only.

Endoscopic transorbital approach to the petrous apex: is orbital rim removal worthwhile for the exposure? An anatomical study with illustrative case.

The endoscopic transorbital approach (ETOA) has been demonstrated to be a feasible ventral route to the petrous apex. Yet, it has been pointed to as a deep and narrow corridor for anterior petrosectomy; particularly, medialization of the instruments can become an issue when targeting the petroclival area. To overcome this limitation, an ETOA with orbital rim removal (ETOA-OR) has been suggested, but not de facto compared, with a transorbital approach without removal of the rim. This addition could augment the surgical exposure and freedom of movement when accessing the petrous apex area. Five human cadaveric heads (10 sides) were dissected. First, anterior petrosectomy was performed via a conventional ETOA (without orbital rim removal). Second, en bloc removal of the orbital rim was performed, with enlargement of the orbital craniectomy and, subsequently, further drilling of the medial petrous apex. Qualitative and quantitative comparisons are provided. An illustrative surgical case is also shown. The transorbital route allowed the authors to perform an anterior petrosectomy in all specimens. The landmarks of bone removal are superposed onto those in the transcranial route. The ETOA-OR increased the volume of craniectomy (from 4.0 mL to 5.5 mL), the lateromedial angulation, and superoinferior angulation of the instruments within the petrous area. Thus, this approach improved the exposure of the medial petroclival area, allowing for an augmented petrosectomy (from 1.4 mL to 2.0 mL, 39.5% increase) and for increased maneuverability, both in the petrous area (from 44.1 cm2 to 76.5 cm2, 73.3% increase) and in the posterior fossa (from 20.2 cm2 to 52.0 cm2, 158% increase). The ETOA-OR was also pragmatically applied to treat a recurrent petroclival meningioma. Complete removal was achieved, the abducens nerve palsy improved, and the trigeminal neuralgia decreased in severity, yet still required medication. The authors provide the first formal anatomical comparison between the transorbital approach with preservation of the orbital rim and a transorbital approach with removal of the rim to access the petrous apex. In addition, an illustrative case is used as a proof of concept and feasibility. According to the authors' data, the ETOA-OR significantly improves surgical exposure and the surgeon's comfort in this deep region. The bony defect can be reconstructed to avoid cosmetic deformities, maintaining the minimally disruptive concept of transorbital surgery.

Uncommon presentation of orbital myositis following herpes zoster ophthalmicus

Herpes zoster ophthalmicus (HZO) is a manifestation of the reactivation of the varicella zoster virus, characterised by vesicular rash along the ophthalmic division of the trigeminal nerve. A rare but significant complication of HZO is orbital myositis, marked by painful swelling of extraocular muscles and periorbital tissues. We present the case of a 72-year-old woman initially presenting with ophthalmological symptoms, notably conjunctival congestion and superficial punctate keratitis, preceding the typical vesicular rash of herpes zoster. The subsequent development of diplopia led to the detection of lateral rectus palsy. Neuroimaging revealed orbital myositis, with the patient showing marked improvement following treatment with oral steroids. This case emphasize the importance of recognizing orbital myositis as a complication of HZO.

Synchronous Ewing sarcoma of the fibula with involvement of the orbit and abducens nerve palsy

Simultaneous or synchronous Ewing sarcoma (ES) is the occurrence of multifocal lesions without pulmonary involvement. This is a very rare condition. We present a case of multifocal synchronous ES of the fibula with orbital involvement and adducens nerve palsy. A 17-year-old boy presented with pain and swelling in both legs for 6 weeks. He was unable to walk due to pain. He was pale and cachexic. There was proptosis and ptosis in the right eye. His investigations were consistent with a multifocal malignant tumor. There were lesions in the left fibula, tibia, right tibia, and right orbit. The histopathological diagnosis was Ewing sarcoma (ES). This is the first report of synchronous ES involving the orbit and abducens nerve.

Listeria Rhombencephalitis: A Case of an Immunocompetent Adult

Listeriosis is one of the most important foodborne diseases, caused by a Gram-positive facultative anaerobic intracellular bacterium found in food and the environment, Listeria monocytogenes. It causes one of the most life-threatening bacterial infections of the central nervous system (CNS). Meningoencephalitis and rhomboencephalitis are the most common forms and immunosuppression represents the main risk factor. In this article, we report a case of severe, invasive Listeria monocytogenes rhombencephalitis in a healthy middle-aged man, admitted to our hospital with meningeal syndrome associated with left VI nerve palsy. No apparent abnormality was found in a head CT and brain magnetic resonance imaging. Following the preliminary LP results, a diagnosis of bacterial meningitis was suspected and empirical antibiotic and antiviral therapy was initiated. Because of the lack of any significant improvement in his clinical status, on day 2 of his admission, a genetic identification of CSF pathogens by high-throughput genome sequencing was performed and identified L. monocytogenes. The Clinical status improved with complete recovery after appropriate antibiotic treatment with sulfamethoxazole-trimethoprim. In conclusion, in an infectious context, pontine involvement should systematically evoke the diagnosis of listeriosis.

A child with unilateral abducens nerve palsy and neurovascular compression in Chiari malformation type 1 resolved with posterior fossa decompression: illustrative case.

Unilateral cranial nerve (CN) VI, or abducens nerve, palsy is rare in children and has not been reported in association with Chiari malformation type 1 (CM1) in the absence of other classic CM1 symptoms. A 3-year-old male presented with acute incomitant esotropia consistent with a unilateral, left CN VI palsy and no additional neurological symptoms. Imaging demonstrated CM1 without hydrocephalus or papilledema, as well as an anterior inferior cerebellar artery (AICA) vessel loop in the immediate vicinity of the left abducens nerve. Given the high risk of a skull base approach for direct microvascular decompression of the abducens nerve and the absence of other classic Chiari symptoms, the patient was initially observed. However, as his palsy progressed, he underwent posterior fossa decompression with duraplasty (PFDD), with the aim of restoring global cerebrospinal fluid dynamics and decreasing possible AICA compression of the left abducens nerve. Postoperatively, his symptoms completely resolved. In this first reported case of CM1 presenting as a unilateral abducens palsy in a young child, possibly caused by neurovascular compression, the patient's symptoms resolved after indirect surgical decompression via PFDD.

MANAGEMENT OF ISOLATED SIXTH CRANIAL NERVE PALSY WITH VIDDHAKARMA AS AN ADJUVANT THERAPY: A CASE SERIES

Background: In Patients with Abducens nerve palsy, diplopia is the most common presenting symptom. Patient will have horizontal uncrossed diplopia which is greater at distance, which worsens in the direction of the palsied muscle and gets better in the contralateral gaze. Vasculopathic risk factors such as diabetes mellitus and hypertension are more common in elderly people due to microvascular ischemia. Treatment options with sixth cranial nerve palsy include alternate patching, prism therapy, strabismus surgery and botulism injections. Here, we present case series of two patients of Isolated Abducens nerve palsy, secondary to Diabetes Mellitus and Hypertension, who underwent Viddhakarma along with other Ayurvedic management. Data were collected prospectively with a follow-up of three months. Case Report: Two cases presented to the Out-patient department with pre-diagnosis of Sixth Cranial Nerve Palsy with signs and symptoms of binocular horizontal diplopia, inability to abduct left eye and mild esotropia secondary to hypertension and diabetes mellitus. In Ayurveda, symptom of Dwitiya Patalgat Doshdushti (Timira) by Acharya Vagbhata and Trutiya Patalgat Doshdushti (Timira) by Acharya Sushruta can be correlated with the diplopia. Snayugata vitiation of Vata Dosha leads to Ekangavata which causes constriction of Sira and Snayu. Thus, sixth cranial nerve palsy can be correlated with Ekangavata and Timira. Viddhakarma as an adjuvant therapy to the Ayurvedic treatment regimen, patients started showing improvement in the symptoms within one to one and a half months and symptoms resolved completely, thereby enhancing the quality of life of the patient. Conclusion: Neuro-ophthalmological cases related to cranial nerve palsies can be treated successfully with Ayurvedic management and Viddhakarma as an adjuvant therapy.

Unrevealing abducens palsy vs. divergence insufficiency: A comprehensive review

Background: The article "Unraveling Abducens Palsy vs. Divergence Insufficiency" provides a comprehensive review of two common ophthalmological conditions, namely Abducens Palsy and Divergence Insufficiency. Aim: In this review article, we aim to unravel the key differences between these conditions, providing healthcare professionals with valuable insights for accurate diagnosis. It provides a comprehensive analysis of the clinical features, diagnostic criteria, etiology, and management strategies for each condition. Methods: A systematic literature search was conducted in electronic databases, including PubMed, MEDLINE, and Google Scholar. Case reports, clinical trials, observational studies, and review articles were considered. The extracted data included information on the clinical presentation, diagnostic tests, etiology, and treatment options for these conditions. Results: The authors emphasize the importance of a thorough ophthalmological examination, including the Hirschberg test and forced duction test, in diagnosing Abducens Palsy accurately. The article also explores the potential causes of Divergence Insufficiency, such as age-related changes and neurologic disorders. The management strategies for both conditions are thoroughly discussed, encompassing both conservative and surgical approaches. Conclusion: The authors present a comprehensive analysis of the clinical features, diagnostic criteria, and management strategies for these two conditions.It serves as a valuable resource for healthcare professionals, providing them with the necessary knowledge to accurately diagnose and manage Abducens Palsy and Divergence Insufficiency. Further research in this field is warranted to enhance our understanding of the underlying mechanisms and optimize treatment outcomes.

Direct V3 Vertebral Artery Access for Embolization of Partially Thrombosed Fusiform Basilar Trunk Aneurysm: Technical Case Instruction.

Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies. An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion. This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible.