Abducens Nerve Paresis Research Articles

Wernicke's Encephalopathy

Wernicke encephalopathy is a thiamine deficiency condition that has a wide range of somatic causes in addition to alcohol abuse. Most patients do not have the classical clinical triad — oculomotor dysfunction, ataxia and cognitive impairment at the onset of the disease, which makes timely diagnosis difficult. The disease may manifest as dizziness, unsteadiness, double vision, or cognitive impairment. Key clinical manifestations include symmetrical gaze-evoked nystagmus, truncal ataxia, bilateral abducens paresis, internuclear ophthalmoplegia, bilateral vestibular-ocular reflex reduction, and anterograde amnesia. To make a diagnosis, the presence of a condition leading to thiamine deficiency is required. The diagnosis is confirmed by MRI, but even with clinical suspicion of Wernicke encephalopathy, it is necessary to initiate parenteral therapy with thiamine in an adequate dose. With timely treatment, the disease has a good prognosis.

Metastatic Intracranial Choriocarcinoma in the Absence of a Primary Lesion: A Case Report

AbstractIntracranial choriocarcinoma is a rare and aggressive neoplasm characterized by the proliferation of trophoblastic tissue. Although choriocarcinoma most commonly arises in the uterus as a component of gestational trophoblastic neoplasia, instances of intracranial choriocarcinoma are exceptionally uncommon. We report a case of intracranial choriocarcinoma without any evidence of a tumor elsewhere. A 25-year-old woman presented with a history of 1 month of evolution with right frontal hemicranial headache, followed by visual disturbances, otalgia, and diplopia. On neurological examination, she was conscious, cooperative, and well-oriented; a grade 1 bilateral papilledema, left homonymous hemianopsia, and sixth cranial nerve paresis, with diplopia, were detected. Neuroimaging showed a right parieto-occipital lesion with features mimicking an atypical meningioma. After surgical resection, a diagnosis of choriocarcinoma was issued. Primary intracranial choriocarcinomas are typically located in the sellar and pineal regions. The occurrence of this tumor within the occipital lobe suggested metastasis; however, a primary tumor in the thoracic or abdominal organs was not observed and a delayed metastasis was considered. This case highlights the diagnostic challenges associated with intracranial choriocarcinoma.

A Rare Case of Clival Hemangioma Simulating Chordoma

AbstractPrimary intraosseous hemangiomas are rare, benign, vascular malformations that account for ∼1% of all primary bone neoplasias. A 59-year-old female patient with unknown comorbidities had a history of headache, visual impairment and dizziness that led to the diagnosis of a clivus tumor. Two resections were attempted through transcranial and transnasal transsphenoidal approach in the last two years in another hospital. The initial MRI scan showed an expansive lesion with T2 hyperintense signal and diffuse, heterogenic contrast enhancement. Clival chordoma was the main diagnostic hypothesis done. A CT scan was performed to evaluate the extent of clival invasion, the sinus anatomy, and the clival destruction - all simulating clival chordoma. The interdisciplinary tumor board decided to proceed with endoscopic endonasal tumor resection. There were no postoperative complications and the histopathological analysis revealed a primary intraosseous haemangioma. Skull base intraosseous hemangiomas are rare entities, with a limited number of case reports found after literature reviews, especially in the clival region. The clinical pattern and imaging characteristics can vary widely according to the tumor extension and development, simulating some other common tumors found at this topography. We present a case report of a clival intraosseous hemangioma presenting as an isolated abducens paresis with a positive outcome after intranasal endoscopic resection after two years of follow-up.

Applying the Full Endoscopic Keyhole Technique to CPA Lesions: A Single-Center Study.

In recent years, endoscopy has become an increasingly common tool used during neurosurgical procedures. However, its application in treating cerebellopontine angle (CPA) lesions has not progressed as rapidly. In this study, the authors present their initial experience with surgically treating CPA lesions using a fully endoscopic keyhole retrosigmoid approach. They conducted a retrospective analysis of clinical data from patients who underwent endoscopic keyhole CPA surgery at their center between May 2017 and April 2022. They provide a comprehensive explanation of this method and an overview of the strategies that have been developed to achieve better clinical outcomes. The study included 107 patients, consisting of 10 cases of vestibular schwannoma, 21 cases of epidermoid cyst, 32 cases of trigeminal neuralgia, and 44 cases of hemifacial spasm. The authors analyzed the clinicodemographic details of the patients. Among the 31 tumor cases, gross total resection was achieved in 25 patients (80.6%), while near-total resection was performed in 6 patients (19.4%). In patients with trigeminal neuralgia, facial pain resolved in 31 out of 32 patients (96.9%). Similarly, facial convulsions disappeared or were relieved in all 44 patients (100%) with hemifacial spasms after the operation. Postoperative complications included facial nerve paresis (n=9, 8.4%), with improvement observed in 6 cases during follow-up, transient facial hypoesthesia (n=3, 2.8%), cerebrospinal fluid rhinorrhea (n=3, 2.8%), transient abducens paresis (n=1, 0.9%), and postoperative hemorrhage (n=1, 0.9%). Endoscopy provides improved deep illumination and, combined with close-up observation, enhances the visualization of structures within the CPA region. The fully endoscopic keyhole technique is a safe and effective method for managing CPA lesions.

Tolosa-Hunt syndrome and recurrent painful ophthalmoplegic neuropathy, case reports: what to do and when?

BackgroundTolosa-Hunt syndrome (THS) and recurrent painful ophthalmoplegic neuropathy (RPON) are rare diseases reported within the “Painful lesions of the cranial nerves” section of the International Classification of Headache Disorders-3rd edition (ICHD-3). In case of a first painful attack, differential diagnosis could be challenging and many pitfalls are due to the rarity of the disorders and the lack of information about correct medical management in youngsters.Case presentationOur main purpose was to report a new case of THS and a new case of RPON describing management and diagnostic investigation at the time of the first episode.In both cases of THS (13 years old) and RPON (14 years old) a unilateral periorbital headache associated with acute onset of ipsilateral third cranial nerve paresis, scarcely responding to non-steroidal anti-inflammatory drugs (NSAID), was present at the beginning of the first attack. Brain MRI with "time-of-flight" (TOF) angiography and the need to administer steroids (after 72 h from onset) in order to stop pain were the most important handles allowing us to adopt the correct management both in THS or RPON since onset and to face recurrences in RPON by avoiding useless therapy during follow-up.ConclusionUnilateral periorbital headache associated with third-fourth or sixth cranial nerve paresis should ideally be investigated with a full work-up, comprehensive of brain MRI with TOF angiography since the first attack. In cases with negative brain MRI spontaneous resolution should be considered and watchful waiting might be advisable before starting steroid therapy.

Moebius syndrome: A case report from Indonesia

Introduction: Moebius syndrome is a neurological condition characterized by congenital facial uniplegia or diplegia due to peripheral type facial nerve paresis and lateral eye movement paresis due to abducens nerve paresis resulting in strabismus. Incidence of Moebius syndrome is 0.27/100,000 live births and often associated with abortion attempts. The following is a case report of Moebius syndrome in Indonesia of a 14-year-old girl with a history of attempted abortion by her mother. Case Report: A 14-year-old girl came with facial muscle complaints in the form of difficulty in raising both eyebrows and closing the mouth since birth. These complaints cause difficulty in eating and drinking. Complaints accompanied by abnormality of the limbs and the number of finger in toes and hands. The patient’s mother had a history of attempted abortion by taking the chemical disinfectant chloroxylenol 4.8% and other drugs. There was bilateral facial nerve paresis and cognitive impairment. On examination of brain magnetic resonance imaging (MRI), it was within normal limits. The patient was planned for physiotherapy and consulted to orthopedics. Conclusion: Moebius syndrome is a collection of rare neurological clinical manifestations in children. Exposure to chemicals during pregnancy can be the etiology of this syndrome in addition to genetics. Management of Moebius syndrome is limited to supportive and symptomatic approach.

Serum Calcitonin Gene-Related Peptide Is Elevated in Patients With Migraine and Ophthalmoplegia.

There is ongoing debate about whether the oculomotor (III), trochlear (IV), or abducens (VI) nerve paresis in patients with migraine is directly attributable to migraine (ophthalmoplegic migraine [OM]) or is due to an inflammatory neuropathy (recurrent painful ophthalmoplegic neuropathy [RPON]). As migraine is associated with elevated serum calcitonin gene-related peptide (CGRP) levels, we studied serum CGRP levels among patients with OM/RPON to determine whether they are elevated during and between attacks. This is the first study assessing CGRP levels in the serum of patients with OM/RPON. The aim of this case-control study was to assess serum CGRP levels in patients with ophthalmoplegia and a headache consistent with migraine according to ICHD-3 criteria. Serum CGRP levels were measured during the ictal and interictal phases in 15 patients with OM/RPON and compared with age-matched and sex-matched controls without migraine (12 patients). The median serum CGRP levels were significantly elevated ( P = 0.021) during the ictal phase (37.2 [36.4, 43.6] ng/L) compared with controls (32.5 [30.1, 37.3] ng/L). Serum CGRP levels during the attack correlated with the total duration of ophthalmoplegia. A CGRP level of 35.5 ng/L in the ictal phase of the attack had a sensitivity of 86.7% and specificity of 75.0% in diagnosing a patient with OM/RPON. Elevated serum CGRP levels during the ictal phase of OM/RPON favor migraine as the underlying cause of episodic headache with ophthalmoplegia.

Cavernous Sinus Swelling and Abducens Nerve Paresis Due to Intracranial Hypotension.

The most common neurological symptom of spontaneous intracranial hypotension (SIH) is abducens nerve paresis, and the precise pathophysiology is unclear. The accepted explanation is traction on the cranial nerves caused by the downward displacement of the cranial content. We herein report magnetic resonance imaging of SIH that can explain the mechanism underlying abducens nerve paresis. The cavernous sinuses were particularly thickened compared with the surrounding dura. This phenomenon can be explained by venous swelling, which can occur after leakage of cerebrospinal fluid in a closed cavity. This swelling pushes the abducens nerve up, which then causes abducens nerve paresis.

Sinus cavernosus-trombose en hersenabces als complicatie van een tandabces

Cavernous sinus thrombosis and brain abscess as a complication of a dental abscess A cavernous sinus thrombosis and brain abscess are rare complications of a dental abscess with a possibly fatal outcome. Therefore, timely and adequate treatment of the cause is important. This case describes a 50-year-old patient who presented to the emergency department with a sudden ptosis of the right eyelid after having suffered for 1,5 months from a dental abscess for which only alternative medicine was applied. Clinical examination showed a dysfunction of the oculomotor nerve and the abducens nerve on the right, and of the abducens nerve on the left. The diagnosis of a cavernous sinus thrombosis and brain abscess were made on an MRI. The brain abscess was drained and antibiotics, initially penicillin and metronidazole IV, later meropenem IV, were started against the multiple anaerobic germs. Anticoagulants were initiated to treat the sinus cavernosus thrombosis and to prevent further cerebral venous embolisation. Ten days later, the patient only showed a partial bilateral abducens paresis, which correlated with the follow-up MRI of the brain, revealing osteomyelitis of the clivus on the course of the abducens. Over-reliance on alternative medicine can be dangerous, especially in those cases where antibiotic therapy is necessary.

Function of oculumotor, trochlear and abducens nerves in patients with cerebral aneurysms undergoing endovascular treatment

Background. Functional impairment of nerves, which move an eyelid, is a serious problem in patients with aneurysms, especially concerning enlarging number of endovascular procedures on cerebral aneurysms.Aim. To evaluate frequency of malfunction of oculomotor, trochlear, abducens nerves in patients with cerebral aneurysms.Methods. From 2019 to 2021 189 patients with 202 aneurysms underwent endovascular treatment. Location of the aneurysms: cavernous, clinoid and communicating segments of the internal carotid arteries, superior cerebellar arteries, P1 and P2 segments of the posterior cerebral arteries. Patients did not have dislocation syndrome as a result of a stroke. There were 37 male patients and 152 female patients. The age of patients ranged from 17 to 78 years, the mean age was 52±12 years. Distribution of aneurysm location: 42 (21%) – cavernous segment of the internal cerebral artery, 25 (12%) – clinoid segment, 110 (55%) – communicating segment, 18 (9%) – superior cerebellar arteries, 7 (3%) – P1 and P2 segments of the posterior cerebral arteries. Morphologically 11 (5%) of the aneurysms were fusiform, 191 (95%) of the aneurysms were saccular. 43 aneurysms (21%) were embolized with coils, 49 (24%) were treated using assisted coiling (balloon- and/or stent-assistance), 83 (42%) of the aneurysms were treated with flow-diverters. 27 (13%) patients underwent several endovascular procedures, including a combination of aforementioned techniques. Function of oculomotor, trochlear and abducens nerves was evaluated at the admission, during the hospitalization and at the discharge. Follow-up was achieved in 102 (54%) patients with 115 aneurysms, the mean follow-up period in June 2022 is 13 months. Checking cerebral angiography was performed 8months after the operation on the average.Results. In 89 (77%) patients checking cerebral angiography showed complete obliteration of the aneurysms, in 26 (23%) filling part of the aneurysm was found out to be smaller. 11 patients had preoperative oculomotor nerve paresis, after the procedure 1 patient had no oculomotor nerve impairment and made a complete recovery, 2 patients had partial improvement, 7 patients had no changes, in 1 patient paresis worsened. In our group we did not observe any case of trochlear nerve palsy either prior or after the operation during follow-up. 6 patients had preoperative abducens nerve paresis, after the treatment 1 patients had a complete recovery of abducens nerve function, 3 patients had partial improvement, 2 patients had no changes.Conclusion. In patients with cerebral aneurysms without cerebral dislocation as result of a stroke function of trochlear nerve did not suffer either prior or after endovascular treatment. Endovascular treatment in this category of patients may positively affect the oculomotor and abducens nerve impairment, but in rare cases it can lead to deterioration of neurological deficit.

Acute occurrence and rupture of a dissecting basilar artery aneurysm in a patient with SARS-CoV-2

The article describes a clinical case of a dissecting basilar artery aneurysm in a patient with SARS-CoV-2. The patient was treated in the infectious diseases hospital for bilateral polysegmental pneumonia on the background of COVID-19. Suddenly, a focal neurological deficit occurred and grew in dynamics in the form of abducens nerve paresis, bulbar disorders, and right-sided hemiparesis. MSCT and MSCT-angiography were performed in dynamics. During the first examination, the pathology of the cerebral vessels was not revealed, but 10 days later, there was detected a fusiform aneurysm of the basilar artery with a diverticulum, the rupture of which led to massive hemorrhage and an unfavorable treatment outcome. The patient's primary symptomatology could be due to impaired blood flow in the perforating branches in the area of the started dissection of the basilar artery.

Hearing Loss and Sixth Cranial Nerve Paresis after COVID-19

An 80-year-old patient was admitted to the internal medicine department for binocular diplopia and hearing loss with sudden onset. The patient had presented with SARS-CoV-2 infection 3 weeks previously and had been admitted to hospital. Complete work-up including autoimmunity, serum and LCR viral serology and MRI did not allow a diagnosis to be established. The hypothesis of a microvascular origin or the previous SARS-CoV-2 infection was considered. The latter was retained in light of the temporal relationship, the absence of other pathologies after exhaustive work-up, and the clinical evolution.LEARNING POINTSA temporal relationship between SARS-CoV-2 infection and symptoms in the absence of other pathologies is important for diagnosis.Mid or long-term follow-up is necessary in patients with unexplained symptoms after SARS-CoV-2 infection.

Vertebrobasilar artery dolichoectasia manifesting as Millard-Gubler syndrome in a young acute ischemic stroke

Introduction: Vertebrobasilar dolichoectasia (VBD) is an arterial disease characterized by dilatation, elongation, and tortuosity of the vertebral and basilar arteries. VBD can generate intracranial hemorrhage, compression of the brainstem, and ischemic stroke as the most common presentation. Millard-Gubler syndrome (MGS) is a pontine-crossed syndrome affecting the pons at the level of the facial nerve nucleus. We present an unusual case of posterior circulation ischemic stroke presenting as MGS due to VBD. Observation: A 50-year-old man, with a medical history of high blood pressure, was hospitalized after 20 hours of transient dizziness, left facial numbness, and diplopia. On examination, he had a right hemiparesis with right Babinski. Deep tendon reflexes were present. Cranial nerves examination showed left abducens paresis with left peripheral facial nerve palsy. Cranial computed tomography (CT) imaging showed left pontine infarct with dilated basilar artery. Brain MRI showed a tortuous and dilated vertebrobasilar system touching the left acoustico-facial complex nerves with a high signal intensity involving the left anterolateral pons with a small right cerebellar hemorrhage. Paraclinical tests showed high blood total cholesterol and bilateral carotid artery atherosclerosis without stenosis. The patient received aspirin, atorvastatin with anti-hypertensive agents. Two weeks after his admission, there was a resolution of the left abducens nerve paresis with mild residual left peripheral facial paresis and left hemiparesis. Discussion: VBD is a complex arteriopathy with unknown etiology. Clinical symptoms in patients with VBD are various including brainstem and cranial nerve compression, intracranial hemorrhage, and ischemic stroke. MGS is an uncommon pontine-crossed syndrome occurring due to a lesion in the pons at the level of the facial nerve nucleus. MGS can be caused by brainstem tumor, cavernous angioma, neurocysticercosis, and cerebral infarction. The coexistence of MGS and VBD is rarer. Conclusion: Our case provides evidence that VBD may be presented as MGS secondary to a posterior circulation ischemic stroke. Therapeutic management of patients with VBD requires a careful balancing of the benefits and risks.

Case report of unilateral abducens nerve paresis: A common sign with an uncommon etiology

Sixth nerve paresis is a rare presentation of intracranial aneurysms. We report an uncommon case of unilateral sixth nerve paresis in a young adult as the main presenting feature of an intracavernous aneurysm. The patient presented with pain and double vision in the right eye for 1 month. Computerized Tomography scan brain done elsewhere was normal. Examination showed right sixth nerve paresis with sensory loss in the first and second divisions of the trigeminal nerve. We suspected a cavernous sinus lesion and conveyed the same to the radiologist who therefore did additional and appropriate imaging, which revealed an intracavernous carotid aneurysm. This case is unique as to the best of our knowledge, it is the first case of its kind reported from India.

Diagnostic particularities and multimodal therapeutic and rehabilitation approches to a complex case of post ischemic stroke with dyshphagia and dysphonia, associating Millard-Gubler and Wallenberg syndromes- case report

Introduction. Millard-Gubler syndrome (MGS), also known as the ventral pontine syndrome or hemiplegic syndrome, is one of the classical crossed syndromes characterized by a unilateral lesion of the basal portion of the caudal part of the pons. MGS manifests as ipsilateral palsy of CN VI and VII with contralateral hemiplegia. Wallenberg syndrome or lateral medullary syndrome, is characterized by the triad of Horner's syndrome, ipsilateral ataxia and contralateral hypoalgesia. Other clinical symptoms may include difficult swallowing, slurred speech, vertigo, nausea, vomiting, dyspnea, tachycardia, headaches and muscular hypertonia. Materials and Methods Having the patient’s consent and The Teaching Emergency Hospital “Bagdasar-Arseni” Ethics Committee N.O 20270 from the 26th of June 2019, the current case report presents a 67-year-old male patient from rural area with left hemiplegia (complete brachial and crural motor deficit), right eye abduction paresis, dysphagia, dysphonia, central facial palsy - all post acute ischemic stroke. The patient was also diagnosed with ischemic cardiomyopathy, atherosclerosis, alcoholism, type 2 diabetes with Insulin therapy and oral antidiabetic agent. The patient was admitted in the Neurorehabilitation Clinic of the Teaching Emergency Hospital „Bagdasar-Arseni” (TEHBA) Bucharest, Romania, associating severe alteration in self-care abilities, locomotor dysfunction, memory disorders, slurred speech, for specialized rehabilitation treatment and nursing. Results. A case of rare pathology for which, unfortunately, there is a discrepancy between functional improvement and the poor motor control in the in the lower limbs (muscle force was 0-1 out of 5 on the Medicale Research Council scale), within an overall favorable evolution, including elements of the clinical status afferent to the two above mentioned syndromes. Conclusions. Approaching such a clinical case has been a complex and extensive challenge for the entire neuromuscular recovery team and remains similar for any other squad. This pathology remains an issue that demands our earnest attention. Key words: Millard-Gubler syndrome (MGS), Wallenberg syndrome, crossed syndromes, hemiplegia, neurorehabilitation, stroke

HEMATOMA EXTRADURAL DE VÉRTEX: A PROPÓSITO DE UM CASO CLÍNICO

Hematomas extradurais de vértex (HEVs) são entidades raras e que apresentam taxa de mortalidade entre 18 e 50%. Os HEVs são altamente associados às fraturas de vértice e diástase das suturas cranianas. Apresentamos o caso de um paciente jovem, masculino, que apresentou TCE após queda de própria altura durante atividade física coletiva, resultando em perda da consciência seguida de cefaleia intensa e vômitos persistentes. Foi realizada TC de crânio, a qual evidenciou HEV e fratura do tipo diastásica da sutura sagital, associada a contusão hemorrágica frontobasal e bifrontal. Foi optado por realizar tratamento conservador em unidade de terapia intensiva, realizando exames neurológico e de imagem seriados. O paciente manteve cefaleia durante todo o internamento, evoluindo com paresia incompleta do nervo abducente à direita, com resolução completa da paresia ao 10° dia. Após alta hospitalar, o paciente manteve acompanhamento ambulatorial, apresentando resolução completa do hematoma após 60 dias; no entanto, apresentou-se com anosmia bilateral durante todo o período em que esteve em acompanhamento.

Surgical Nuances of Endoscopic Endonasal Upper Clivectomy for Radical Resection of Central Skull Base Tumors: Two-Dimensional Operative Videos

Abstract INTRODUCTION With routine endoscopic endonasal approach (EEA) for resection of skull base tumors, it is difficult to remove tumors that extend behind the posterior clinoid process (PCP) and dorsum sellae due to the limited exposure. Critical neurovascular structures (internal carotid artery, cavernous sinus, pituitary gland), PCP and dorsum sellae obstruct tumor visualization. Posterior clinoidectomy gives an excellent wider operative view and allows radical resection of tumors in the retrosellar area, prepontine and interpeduncular cisterns. We modified the endoscopic posterior clinoidectomy for safer endonasal extradural posterior clinoidectomy and applied it in 44 patients with parasellar and retrosellar tumors. This is the largest clinical series of endonasal extradural posterior clinoidectomy in which the clinical outcomes were evaluated. METHODS An extradural upper clivectomy (with complete posterior clinoidectomies) following lateral retraction of the paraclival internal carotid artery and extradural pituitary transposition were applied while preserving the blood supply and venous drainage of the pituitary gland. No violation to the cavernous sinuses. In cases with prominent posterior clinoid process, a midline sellar dura cut was added to facilitate its extradural exposure. Forty-four consecutive patients, in whom this technique was performed, between 2016 and 2018 at Osaka City University Hospital, were reviewed. The pathology included 19 craniopharyngiomas, 7 chordomas, 6 meningiomas, 6 pituitary adenomas, 4 chondrosarcomas, and 2 miscellaneous. Utilization and effectiveness of this approach were further demonstrated with neuroimaging. RESULTS On radiological examination, the surgical field was 2.2 times wider in cases with bilateral posterior clinoidectomies than in cases without posterior clinoidectomy. Upper clivectomies were successfully applied in all patients without permanent neurovascular injury, with better maneuverability and greater resection rate of the tumors. Four patients experienced transient postoperative abducens nerve paresis, and one patient experienced transient postoperative oculomotor nerve paresis; nevertheless, the deficits recovered within 3 mo. CONCLUSION The extended EEA with extradural upper clivectomy creates an extra-working space and allows adequate accessibility with safe surgical maneuverability to remove tumors that extend behind the posterior clinoid and dorsum sellae.

Surgical implementation and efficacy of endoscopic endonasal extradural posterior clinoidectomy.

The endoscopic endonasal approach (EEA) for skull base tumors has become an important topic in recent years, but its use, merits, and demerits are still being debated. Herein, the authors describe the nuances and efficacy of the endoscopic endonasal extradural posterior clinoidectomy for maximal tumor exposure. The surgical technique included extradural posterior clinoidectomy following lateral retraction of the paraclival internal carotid artery and extradural pituitary transposition. In cases with prominent posterior clinoid process, a midline sellar dura cut was added to facilitate extradural exposure. Forty-four consecutive patients, in whom this technique was performed between 2016 and 2018 at Osaka City University Hospital, were reviewed. The pathology included 19 craniopharyngiomas, 7 chordomas, 6 meningiomas, 6 pituitary adenomas, 4 chondrosarcomas, and 2 miscellaneous. Utilization and effectiveness of this approach were further demonstrated with neuroimaging. Extradural posterior clinoidectomies were successfully applied in all patients without permanent neurovascular injury and with better maneuverability and greater resection rate of the tumors. Four patients experienced transient postoperative abducens nerve paresis, and 1 patient experienced transient postoperative oculomotor nerve paresis; however, the patients with deficits recovered within 3 months. On radiological examination, the surgical field was 2.2 times wider in cases with bilateral posterior clinoidectomy than in cases without posterior clinoidectomy. The extended EEA with extradural posterior clinoidectomy creates an extra working space and allows adequate accessibility with safe surgical maneuverability to remove tumors that extend behind the posterior clinoid and dorsum sellae.

A case of Isolated left Abducens Nerve paresis and Pituitary macroadenoma

A case of Isolated left Abducens Nerve paresis and Pituitary macroadenoma

Endoscopic Keyhole Retromastoid Approach in Neurosurgical Practice: Ant-Man's View of the Neurosurgical Marvel

Endoscopy is now a staple of any neurosurgical practice. The versatility of this approach and gratifying results has resulted in its increased popularity. The objective of this paper is to report our experience of managing various cerebellopontine angle (CPA) pathologies by endoscopic keyhole retromastoid suboccipital craniectomy (RMSO) approach. A retrospective review of the medical records of patients operated in our department by endoscopic keyhole RMSO approach was done along with a collection of relevant patient particulars. Forty-four patients (24 men and 20 women) were operated via an endoscopic keyhole RMSO approach for various lesions in and around the CPA. The craniectomy was of 2.0-2.5 cm in size. An endoscope was used as the sole visualizing tool throughout the procedure in all cases. Primarily 2 kinds of pathologies were approached: neoplasms, mostly benign (n= 33), and vascular loops (n= 11). The extent of excision in 33 tumor cases was gross total (n= 20), near total (n= 12), and subtotal (n= 1). In cases of a vascular loop, microvascular decompression was performed. Anatomic facial nerve preservation was ensured in all cases of vascular loops and in 30 tumor cases. Postoperative complications included new-onset/worsening of facial nerve paresis (n= 12, 27.3%), 9 of which improved in follow-up, transient facial hypoesthesia (n= 2, 4.5%), transient abducens paresis (n= 4, 9%), transient lower cranial nerve paresis (n= 3, 6.8%), pseudomeningocele (n= 1, 2.3%), cerebrospinal fluid leak with meningitis (n= 1, 2.3%) and operative site hematoma (n= 1, 2.3%) which required evacuation. Endoscopic keyhole RMSO approach is minimally invasive and yields an excellent outcome in the management of various CPA lesions.