Bilateral Abducens Nerve Palsy Research Articles

Single-Stage Endoscopic Repair of Pediatric Basal Encephalocele: A Comprehensive Multimedia Case Report.

Basal encephaloceles are the result of a concomitant cranial and dural defect that allows for inferior displacement of cerebral tissue, meninges, and cerebrospinal fluid into the paranasal sinuses and outside the cranial vault. This work illustrates a step-by-step surgical approach of a successful single-stage, endoscopic repair of a congenital basal encephalocele in a 10-year-old child, using a free mucosal middle turbinate graft that provided effective results without utilization of traditional open reconstructive techniques or vascularized flaps. A previously healthy 10-year-old male with a history of unilateral clear rhinorrhea was admitted as an inpatient because of an acute episode of nausea, vomiting, and confusion, accompanied by fever, diplopia, and bilateral abducens nerve palsies. Preoperative imaging revealed a 2-cm right-sided intranasal mass accompanied by a subcentimeter skull base defect spanning the lateral lamella. After completing a course of intravenous antibiotic therapy for 1 week after a negative lumbar puncture to ensure clearance of intracranial infection, the decision was made to proceed with definitive endoscopic skull base repair to obviate recurrent bacterial meningitis episodes and potential neurological complications. This study demonstrates technical feasibility of a single-stage endoscopic endonasal approach for pediatric basal encephalocele resection and repair which minimizes craniofacial morbidity associated with traditional open approaches and sinonasal morbidity associated with local pedicle-based flaps for small cranial base defects in this unique patient population.

Isolated traumatic retroclival interdural hematoma causing craniocervical instability: A case report of pathology in a rare location and literature review

Introduction. Retroclival hematomas (RCH) are a rare entity primarily as a post-traumatic phenomenon in the pediatric population. We present a case of Retroclival interdural hematoma in a 12 y/o female with a previous record of craniocervical trauma. A RCH is identified initially by CT and easily overlooked. MRI cervical spine to evaluate the Tectorial membrane and other craniocervical ligaments integrity. Case report. A 12-year-old female presented with bilateral abducens nerve palsies and a Glasgow Coma Score (GCS) of 13 following a high-speed motor vehicle accident. Initial CT brain revealed an infra-tentorial extra-axial focal hyperdense collection (hemorrhage) along the retroclival region in the interdural space measuring approximately 9 × 29 × 58 mm. Subsequent imaging and evaluations suggested cranio-cervical instability, leading to surgical intervention. Conclusions. Prompt diagnosis of RCH with conservative or surgical management is essential to avoid neurological deficits and mortality. Despite the significant potential for morbidity and mortality, the majority of patients show a benign clinical course with conservative care, underscoring the importance of quick diagnosis and close observation.

Multiple Primary Malignancies and Bilateral Vocal Cord Paralysis Confusing the Management of Each Other

AbstractDouble primary malignancy though uncommon, we often encounter in our clinical practice. The lung malignancy is known to cause left vocal cord paralysis. Bilateral abductor paralysis secondary to adenocarcinoma of the lung with concurrent basal cell carcinoma of the face is not common. Proper counseling and timely management are needed in these cases of multiple primary malignancies. Early evaluation in all cases of hoarseness can help in early diagnosis and management.

Right-sided Herpes Zoster Ophthalmicus Complicated by Bilateral Third, Fourth, and Sixth Cranial Nerve Palsies and Syndrome of Inappropriate Antidiuretic Hormone Secretion: A Case Report.

Cases of herpes zoster ophthalmicus (HZO) complicated by bilateral ophthalmoplegia are rare, and no cases of bilateral third, fourth, or sixth cranial nerve palsies have been reported. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a rare complication of HZO. We herein report an 80-year-old Japanese woman with right-sided HZO complicated by meningoencephalitis and discuss the pathogenesis of this condition. She developed bilateral third, fourth, and sixth cranial nerve palsies and SIADH almost simultaneously during treatment for HZO. The bilateral cranial palsy spontaneously resolved within a few months.

Bilateral abducens nerve palsy from post-spinal-anesthesia-induced bilateral chronic subdural hematoma: case report

BackgroundA chronic cranial subdural hematoma arising after post-spinal anesthesia is a rare but serious and life-threatening complication of spinal anesthesia. It usually mimics the typical post-spinal-anesthesia headache or post-dural-puncture headache, potentially masking its detection. Abducens nerve palsy tends to occur in chronic subdural hematoma of post-dural-puncture etiology rather than in cases attributed to other causes of subdural hematoma. Preferential damage to the abducens nerve is frequent and can be attributed to its anatomic course because the abducens nerve runs in the direction of the typical caudad displacement of the brain related to intracranial hypotension.ObservationHere, we present a report on the clinical presentation, pathogenesis, and management of two cases that developed bilateral abducens nerve palsy following post-spinal anesthesia administered for cesarean sections due to obstetric indications.LessonPost-spinal-anesthesia-induced chronic subdural hematoma, although a rare, life-threatening complication, must be differentiated from post-spinal-anesthesia headache and treated surgically. Cranial nerve palsy (more commonly called abducens nerve palsy) is more common in post-spinal-anesthesia-induced subdural hematoma than subdural hematomas of other etiologies as the cerebrospinal fluid brain cushioning is partly lost. Cranial nerve palsies resolve in most cases if surgery is performed in a timely manner.

Bilateral Abducens Nerve Palsy and Nystagmus Resolved Upon Intravenous Dextrose Administration in Hypoglycemic Young Female: A Case Report and Review of the Literature

Hypoglycemia can cause a variety of neurological symptoms ranging from mild confusion to seizures and coma. The brain depends heavily on glucose as its main energetic resource, and a decrease in glucose levels can lead to impaired cerebral function. A 38-year-old female presented to the Emergency department with a history of headache, dizziness and asymmetric reactive pupils in addition to bilateral medial strabismus, nystagmus and photophobia. A non-contrast brain Computed Tomography scan was performed showed no significant radiological findings. Laboratory tests were within normal ranges except for a clinically significant hypoglycemia (level II). Intravenous dextrose was administered and strabismus gradually resolved, and headache subsided gradually within an hour. Hypoglycemic state should be investigated first in any patient with sudden neurological deficit.

Idiopathic Intracranial Hypertension with Disproportionately Enlarged Subarachnoid Space Hydrocephalus on Imaging: A Case Report.

The pathophysiology of idiopathic intracranial hypertension (IIH) and idiopathic normal-pressure hydrocephalus (iNPH) differs in terms of cerebrospinal fluid (CSF) pressure and imaging-related characteristics. A 51-year-old man presented with optic nerve papillary edema, visual disturbance, bilateral abducens nerve palsy, and a wide-based gait. Imaging showed characteristic findings of IIH and disproportionately enlarged subarachnoid space hydrocephalus (DESH)-characteristic of iNPH. A CSF examination revealed marked CSF hypertension. IIH with iNPH-like imaging features (DESH) was diagnosed, and ventriculoperitoneal shunt surgery was performed. Postoperatively, the visual acuity and visual field improved. This report also describes the distinct and overlapping pathophysiological mechanisms of IIH and iNPH.

Case Report: Bilateral optic disc swelling in a patient with tuberculoma

BACKGROUND: In children, tuberculosis of the central nervous system most usually manifests as tubercular meningitis, hydrocephalus post-tubercular meningitis, and, in rare cases, space-occupying lesions known as tuberculoma. We address the diagnostic difficulty in an adult patient with mainly ocular symptoms who was diagnosed with tuberculoma. A 19-year-old young man came with painless bilateral blurring of vision. Bilateral optic disc swelling and bilateral sixth cranial nerve palsy were present. METHODS: Brain imaging revealed ring-enhancing lesions in the cerebellar vermis, left cerebellar hemisphere and left middle cerebral peduncle with surrounding extensive perilesional edema causing effacement of fourth ventricle leading to obstructive hydrocephalus suggestive of tuberculoma. RESULTS: He had a high erythrocyte sedimentation rate and a positive Mantoux test. His Quantiferon-TB Gold test result was positive. The examination of cerebrospinal fluid suggested a high opening pressure. Following anti-tubercular medication along with systemic steroids, his vision improved due to decreased optic disc swelling. CONCLUSION: We wish to highlight that visual loss and grave consequences of tuberculoma can be averted with early recognition and treatment.

Pneumococcal Cerebrospinal Meningitis: A Rare Complication of Pediatric Temporal Bone Fracture

Meningitis is a rare and potentially serious complication in children with temporal bone fractures. We present an unusual case of a 7-year-old girl with pneumococcal meningitis complicated by cerebrospinal fluid (CSF) leakage following transverse fracture in the left temporal bone. She had an otorrhea resolved spontaneously in the early stage of hospitalization. At 4 days post-discharge, the patient returned with headache, fever, neck stiffness, voiding difficulty, and bilateral abducens nerve palsy. Magnetic resonance images demonstrated an intense uniform contrast enhancement in the cerebral cisterns and the sacral nerve roots. Laboratory analysis and culture diagnosed meningitis caused by <i>Streptococcus pneumonia</i>. She was discharged home after getting intravenous ceftriaxone for 5 weeks. Follow-up for the patient required constant vigilance and included a multidisciplinary approach. At 7 months after head trauma, the child was well with no neurological and auditory deficits. This case illustrates a previously unreported complication in pediatric patient of temporal bone fracture associated with CSF otorrhea.

INDICATIONS AND COMPLICATIONS OF TRACHEOSTOMY AT A TERTIARY CARE INSTITUTE: A PROSPECTIVE AND OBSERVATIONAL STUDY

Objective: The aim of the present study was to present an analysis of indications and complications of tracheostomy in tracheostomized patients. Methods: This was a single center, hospital-based prospective, non-randomized, and non-comparative study involving 60 tracheostomized patients carried out from February 2021 to March 2022 at Geetanjali Medical College and Hospital, Udaipur, India. Results: Out of 60 tracheostomies performed most common indications were Laryngo-tracheal trauma (26.7%), organophosphorus poisoning (25%), malignancy of Larynx (11.67%), post-intubation stenosis (6.7%), bilateral abductor paralysis (6.7%), head injury (6.7%), meningitis (5%), acute laryngo-traheo-bronchitis (3.33%), hypoxic-ischemic-encephalopathy (3.33%), cerebrovascular accidents (1.67%), faucial diptheria (1.67%), and GB syndrome (1.67%). Out of 60 tracheostomies performed, 18 complications were encountered. The most common complication was granulations of tracheostoma which occurred in 5 cases (8.3%), three cases of tube occlusion (5%), three cases had difficult decannulation (5%), three cases developed infection of stoma (5%), two cases developed surgical emphysema (3.3%), one case of tracheostomy scar hypertrophy (1.6%), and one case developed tracheal stenosis (1.6%). Conclusion: Tracheostomy is the procedure of choice especially in cases. Where it is needed to provide prolonged positive pressure ventilation and tracheobronchial toilet. Thorough anatomical knowledge of trachea and adjacent structures, skill of surgeon, sterile technique, meticulous surgery, use of high-volume low pressure cuffed Portex tracheostomy tubes, and good bedside tracheostomy care results in minimal complications. Complications of tracheostomy are largely preventable.

頸髄損傷に合併した経鼻胃管症候群の1例(A case of nasogastric tube syndrome with cervical spinal injury)

経鼻胃管症候群とは，経鼻胃管留置後に咽頭痛，両側声帯の外転麻痺，喉頭浮腫を発症する症候群である。両側声帯麻痺を認めれば気道緊急を要し，しばしば致命的となる。症例は46歳の男性。墜落外傷により当院搬送となった。精査の結果，外傷性くも膜下出血，第6・7頸椎・第6–10胸椎骨折，第6・7頸髄・第6–8胸髄損傷と診断し，入院加療を開始した。第2病日麻痺性イレウスを発症し，経鼻胃管を留置し，減圧加療を開始した。第11病日吸気性喘鳴を聴取し，酸素8L/分投与下でSpO2（経皮的酸素分圧）88%まで低下を認めた。喉頭ファイバースコピー検査で両側声帯麻痺を認め，気道緊急として経口気管挿管を施行し，人工呼吸管理を開始した。第14病日気管切開術を施行した。第39病日声帯麻痺の治癒を確認した。第45病日リハビリテーション目的に転院した。 Nasogastric tube syndrome presents as throat pain, bilateral abductor paralysis of the vocal cords and pharyngeal edema after nasogastric tube placement. This syndrome often requires emergency airway management due to bilateral abductor paralysis and thus can be fatal. A 46–year–old man was transported to the emergency room due to trauma from a fall. We diagnosed traumatic subarachnoid hemorrhage, cervical and thoracic spine fractures, and cervical and thoracic spinal cord injury, and admitted him. On hospital day 2, a nasogastric tube was inserted due to paralytic ileus. On day 11, wheezing was heard on exhalation, and his SpO2 decreased to 88% on oxygen at 8L/min. Laryngeal fiberscopy revealed bilateral vocal cord paralysis, so he was intubated orally. A tracheotomy was performed on day 14. The vocal cord paralysis had healed by day 39, and on day 45, he was transferred to another hospital for rehabilitation. 経鼻胃管症候群とは，経鼻胃管留置後に咽頭痛，両側声帯の外転麻痺，喉頭浮腫を発症する症候群である。両側声帯麻痺を認めれば緊急気道確保を要し，しばしば致命的となる。今回，頸髄損傷を背景として経鼻胃管留置中に両側声帯麻痺を発症した1例を経験したので報告する。 当論文は当院倫理委員会の承諾を受け，個人情報保護法に基づいて匿名化を行っている。また，患者およびその家族から論文の出版に関する同意を得ている。 患 者：49歳の男性。身長180cm，体重91.6kg，BMI 28.3 既往歴：統合失調症 内服薬：アリピプラゾール，フルニトラゼパム，ゾルピデム酒石塩酸，クエチアピンフマル酸塩，アムロジピンベシル酸塩 現病歴：自宅3階からの飛び降りによる転落外傷で受傷した。目撃者が救急要請し，当院救急搬送となった。 来院時現症：気道は開通，呼吸音 清，呼吸様式 正常，呼吸数16/分，SpO2 97%（酸素10L/分 投与下），血圧85/45mmHg，脈拍72/分，Glasgow coma scale E3V5M6，瞳孔径2mm/2mm，対光反射は両側迅速，体温36.2度（腋窩温）であった。 身体所見：後頭部に約20cmの裂創を認めるが活動性出血は認めなかった。右膝・両踵に擦過傷を認めた。徒手筋力テストは両上下肢いずれもMMT 3以上であるが，意思疎通がとれず，詳細な評価は困難であった。持続勃起や肛門括約筋の弛緩は認めなかった。 血液検査：WBC 17,300/µL（Neut 89.4%），Hb 16.4g/dL，Plt 34.9×104/mm3，PT–INR 1.17，Fibrinogen 180mg/dL，APTT 22.2秒，D–dimer 41.21µg/mL 動脈血液ガス分析（酸素マスク10L/分投与下）：pH 7.359，PaCO2 38.0mmHg，PaO2 148.1mmHg，HCO3− 20.9mmol/L，B.E. −4.0mmol/L，lactate 29.2mg/dL 全身CT画像検査：外傷性くも膜下出血，第6・7頸椎棘突起骨折，左第4・5肋骨骨折，第6–8・10胸椎椎体骨折を認めた。 来院時ショックの状態であり，神経原性ショックの可能性を念頭に置いて診療したが，輸液負荷のみで血圧は安定し，入院加療を開始した。血液検査でのWBCおよびD–dimerの上昇は外傷に起因するものと判断した。第2病日，腸蠕動音減弱および腹部レントゲン検査で小腸の拡張を認め，麻痺性イレウスと診断し，減圧目的に20Frの経鼻胃管を留置した。第3病日下肢の筋力低下の訴えがあり，頭部・頸椎・胸椎MRI撮像したところ，T2強調像で第6椎体前面および第6–7頸髄内，第6–8胸髄内の高信号を認め，第6–7頸髄損傷，第6–8胸髄損傷と診断した（Fig. 1）。頸椎カラー装着継続で保存加療の方針とした。リハビリテーション目的の転院調整を開始しようとしたが，第11病日突然の吸気性喘鳴を認め，ボスミン筋肉注射を行うも改善を認めなかった。喉頭ファイバースコピー検査で両側声帯麻痺と診断した（Fig. 2A）。次第にSpO2は低下し，酸素8L/分 投与下にSpO2 88%前後まで酸素化低下を認めた。その時点での動脈血液ガス分析では，pH 7.501，PaCO2 48.8mmHg，PaO2 67.9mmHg，HCO3− 37.3mmol/L，B.E. 12.5mmol/L，lactate 11.8mg/dLと低酸素血症，高二酸化炭素血症を呈していた。経口気管挿管による気道確保を行い，人工呼吸管理を開始した。その後は原因検索を行ったが器質的疾患はいずれも否定的で，経鼻胃管症候群と診断した。麻痺性イレウスは遷延しており，経鼻胃管の抜去は困難であったため，第13病日経鼻胃管を18Frに入れ替えた。長期の気管挿管となることが予想され，第14病日気管切開術を施行した。腸蠕動音正常，腹部レントゲン検査で小腸の拡張の改善を認め，麻痺性イレウスの治癒と判断し，第16病日栄養投与目的に経鼻胃管を10Frに入れ替えた。第39病日喉頭ファイバースコピー検査で声帯麻痺の治癒を確認した（Fig. 2B）。精神状態悪化による昏迷状態となっており，気管切開チューブはスピーチカニューレへの入れ替えにとどめた。第45病日頸椎カラーは装着を継続しリハビリテーション目的に転院した（injury severity score: 17，probability of survival: 0.97972であった）。 Magnetic resonance imaging of the cervical and thoracic vertebrae. MRI（T2）revealed spinal cord injury at the sixth and seventh cervical vertebrae and from the sixth to eighth thoracic vertebrae (red arrow), and 5–mm retropharyngeal hematoma (yellow arrow). Laryngeal fiberscopy. A: Laryngeal fiberscopy showed abnormal abducton of the vocal cords. (during the phase of expiration (left) / inspiration (right)) B: Laryngeal fiberscopy showed recovery of the vocal cords from abductor disorder. (during the phase of expiration (left) / inspiration (right)) Cervical computed tomography (CT). Computed tomography revealed a 6–mm retropharyngeal hematoma (red arrow). 経鼻胃管による咽頭への影響は1939年Wangensteen 1により初めて報告され，その後しばしば症例報告が散見される程度であった。1981年Sofferman 2は，経鼻胃管留置中に咽頭痛，片側あるいは両側の声帯の外転機能不全を来す症候群を経鼻胃管症候群と定義した。診断は，喉頭ファイバースコピー検査で声帯麻痺と診断し，かつ原因となりうる疾患を除外したうえで，臨床的に診断することが多い。発症のタイミングは経鼻胃管を留置して12時間後から抜去2週間後まで多様である 3。 病態は完全には解明されておらず，機序として，①咳嗽や嚥下の際に固定された経鼻胃管と咽頭が垂直方向へ摩擦が起きること，②仰臥位で輪状後部が頸椎側から経鼻胃管により圧迫される，③輪状咽頭筋の収縮が経鼻胃管を脆弱で薄い輪状軟骨後板へ持続的に引き上げる，といったことが推測されている 2。その結果，経鼻胃管による輪状後部への持続的圧迫から結果的に潰瘍形成や感染，虚血が生じ，後輪状披裂筋の機能不全が生じると考えられている 2, 4。糖尿病や低免疫状態，低栄養，加齢に伴う粘膜弾性の低下，パーキンソン症候群，脳血管障害に伴う生理的な嚥下運動の減少による除圧頻度の減少，輪状軟骨レベルでの骨棘突出がリスク因子と言われている 2, 5, 6。経鼻胃管の太さがリスク因子とする報告はない。桜井ら 7による10Frの経鼻胃管を留置していた4例の報告があり，決して細いチューブがリスクを軽減するわけではないと考えられる。またチューブの径が太い方が輪状後部への影響を与える可能性は高く，リスクとなりうると考えるが，今後検討すべき事項である。Friedmanらは，経鼻胃管が声帯部を正中で走行するのは約6%と少ないものの，動物モデルで側方を走行するより正中を走行する方が炎症を生じやすい可能性があると報告している 8。 本症例において，初療時のCT画像や第3病日のMRI画像では声帯自体や輪状軟骨後部を含め声門周囲の直接的な外傷性変化は指摘できなかった。咽頭後間隙の血腫は第1病日のCTで6mm，第3病日のMRIで5mmであった（Fig. 1, 3）。リスク因子は入院後に発症した麻痺性イレウスの影響による低栄養のみであった。経鼻胃管はCT画像で確認する限り，声門部では側方を通過していた。喉頭ファイバースコピー検査の際も側方を通過しているのを確認できた。入院後は頸髄損傷のため，仰臥位での安静時間がほとんどであった。しかし，頸髄損傷で経鼻胃管の留置が必要であった患者はこれまで多く経験しているが，当院で経鼻胃管症候群と診断したのは初めてであり，頸髄損傷などで輪状軟骨レベルでの損傷がある外傷症例での経鼻胃管症候群の報告は，我々が渉猟する限り見られなかった。以上から，本症例では低栄養状態や長期臥床の影響だけでなく，リスク因子として知られている輪状軟骨レベルの骨棘突出と同様の機序で，頸部外傷による咽頭後間隙の血腫・炎症性変化が経鼻胃管による輪状後部への刺激を増強し，炎症や虚血を起こしたのではないかと考えられた。頸髄損傷に偶発的に合併した可能性は否定できないが，椎体前面の外傷性変化が一因となり，経鼻胃管症候群を発症しうることが示唆された。椎体前面に血腫を形成する頸髄損傷の症例には重症度の差がある。軽症例では，通常経口摂取が可能で経鼻胃管が留置される可能性は高くない。一方，重症例では，腹式呼吸や喀痰喀出困難を原因とした呼吸不全に対する気管挿管のタイミングで経鼻胃管が留置されることが多い。その後十分な声帯の評価が行われずに気道確保や気管切開が行われていることが多く，経過中に経鼻胃管症候群を発症していても認知されていない可能性がある。本症例は腹式呼吸を呈するような重症例ではなかったものの，イレウスを発症したことで経鼻胃管が留置され，頸椎前面の外傷性炎症と相まって，経鼻胃管症候群の発症に至った。それに加え，咳嗽減弱や喀痰喀出困難をそれまで認めていなかったという経過から，本症に気づくことができたのではないかと考えた。 治療は経鼻胃管の抜去が必須とされている 9。その他，抗菌薬やPPI，副腎皮質ステロイドなどが投与された報告はあるが，確立した治療法はない。声帯外転障害が改善せず気管カニューレが抜去できないこともある 3。本症例では，治療上経鼻胃管を抜去することは困難であり，まずは経鼻胃管を減圧の治療の障害にならない範囲で細いものに入れ替えたのちに，経鼻胃管を留置している限り短期間での治癒は見込めないと判断し，気管切開術を行った。発症から29日後に声帯麻痺の治癒を確認できた。検索する限り今まで経鼻胃管を抜去せずに経鼻胃管症候群が治癒したという報告は見られなかった。治癒までの期間は長くなるかもしれないが，本症例のように治療上必要であれば経鼻胃管を抜去せずとも治癒する可能性があることが示唆された。 本症例は外傷症例の亜急性期に発生した吸気性喘鳴を契機に，各疾患を除外してから経鼻胃管症候群と診断できた。経鼻胃管症候群は比較的近年に定義された症候群であり，とくに2010年以降の症例報告が増加している 7, 9。これに関しては，経鼻胃管の留置数が著明に増加しているわけではないと考えられることから，発症する頻度が増加したわけではなく，この疾患の概念が認識され始めたことに影響しているものと推測された。対応が遅れると致命的となりうるだけでなく，本疾患を鑑別に入れておかないと経鼻胃管を抜去するなどの対応が遅れ，治癒までの期間が延長しうる。とくに救命・集中治療部門において経鼻胃管は留置されていることの多いデバイスであり，経鼻胃管を留置する際は本合併症に留意して管理を行う必要がある。 椎体前面の外傷性変化が一因になったと考えられた経鼻胃管症候群の1例を経験した。経鼻胃管はよく留置されるデバイスであり，両側声帯麻痺を発症した場合，緊急気道確保を行うとともに，経鼻胃管症候群を鑑別に挙げて治療を行う必要がある。 本論文の要旨は第122回近畿救急医学研究会（2021年，大阪）で発表した。 本稿のすべての著者に規定された利益相反はない。

Peripheral T-Cell Lymphoma Manifesting as Multifocal Central Nervous System Disease with Prominent Spinal Cord Involvement (P2-13.001)

<h3>Objective:</h3> To emphasize the need for timely and wide-reaching diagnostic testing in the evaluation of acute-onset multifocal CNS disease with prominent spinal cord involvement. <h3>Background:</h3> Metastatic CNS neoplasms, although rare, should be considered early in rapidly declining patients with multifocal disease in whom immune-mediated or infectious etiologies have been excluded. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 53-year-old male with Celiac disease on azathioprine presented with one-week of vertigo, diplopia, and dysarthria upon one-year of malaise and cachexia. The patient’s examination revealed right eyelid ptosis, bilateral abducens palsies, restricted up-gaze, dysarthria, and diffuse dysmetria and hyporeflexia. MRI showed a right T2 hyperintense contrast-enhancing cerebellar lesion and a small left cerebellar diffusion-restricting lesion. CSF was inflammatory (nucleated cell 6 cells/mcL, protein 181 mg/dL, glucose 30 mg/dL). Workup for autoimmune encephalitis, myelin-oligodendrocyte-glycoprotein-IgG, aquaporin-4-IgG, and infections etiologies were negative. He was empirically treated with intravenous methylprednisolone and immunoglobulin without benefit. He continued to decline and repeat CSF was again inflammatory (28 cells/mcL, protein 494 mg/dL), without clonal cells. Repeated MRI showed new left frontal leptomeningeal and cauda equina enhancement extending into the adjacent musculature. Electromyography showed proximal myopathy and subsequent biopsy was unrevealing. A bone marrow and brain biopsy were declined due to development of pulmonary embolism and multiorgan failure. He continued to decline and developed multifocal strokes, expiring 6 weeks after presentation. Autopsy demonstrated peripheral T cell lymphoma (PTLC). <h3>Conclusions:</h3> Intramedullary non-CNS spinal metastases represent less than 8.5% of all metastatic tumors and 3% of all spinal metastases. PTCL represents 15% of non-Hodgkin lymphomas and can rarely involve the CNS parenchyma or leptomeninges. Persistent enhancement, elevated protein, and minimal response to steroids or subsequent rebound should raise suspicion for neoplasm, especially considering these patients’ rapid decline can make CNS biopsy inadvisable later in the disease course. <b>Disclosure:</b> Dr. Singh has nothing to disclose. Dr. Carozza has nothing to disclose. Dr. Misulis has received publishing royalties from a publication relating to health care. Dr. Shah has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Horizon. Dr. Shah has received publishing royalties from a publication relating to health care.

Huge Arachnoid Cyst Presented with Bilateral Sixth Cranial Nerve Palsy

Huge Arachnoid Cyst Presented with Bilateral Sixth Cranial Nerve Palsy

Expressionless Physiognomy–A Case of Moebius Syndrome

Moebius syndrome (MBS) is a rare neurological disorder which characterized by bilateral or unilateral facial nerve weakness with bilateral abducens nerve palsy. It can affect multiple cranial nerves with an incidence of 2–20 cases per million births. We report a 6 years female child with MBS with morpho-functional deficits and developmental problems.

BILATERAL ABDUCENS NERVE PALSY AFTER A RUPTURE OF AN ANTERIOR COMMUNICATING ARTERY ANEURYSM: A CASE REPORT AND LITERATURE REVIEW

A rare case of bilateral abducens nerve palsy occurred in a 60-year-old man hospitalized after a sudden severe headache and horizontal binocular diplopia. The patient did not present others neurological manifestations. A Computed Tomography (CT) revealed a subarachnoid hemorrhage, and the arteriography showed an ACoA aneurysm. After the aneurysm embolization, the patient continues to evolve with maintenance of the condition. Bilateral abducens nerve palsy can occur due to several factors, but its pathophysiology associated with the rupture of aneurysms in ACoA has several gaps in knowledge and scarce literary support. Thus, the need for studies in this field is pointed.

Bilateral sixth cranial nerve palsy following lumboperitoneal shunt

Lumboperitoneal (LP) shunt is considered as a unique procedure in neurosurgical practice. The over drainage of Cerebrospinal fluid (CSF) is considered a usual side effect of the procedure that usually manifests in the form of subdural collection, headache, or nausea and vomiting. However, cranial nerve palsy, particularly abducens nerve palsy, is a rare manifestation of CSF over drainage. We describe our experience with a patient that has developed bilateral sixth nerve palsy followed by LP shunt insertion, with resolution of the symptoms upon removal of the shunt. This shades the light on a rare but significant complication related to Lumboperitoneal (LP) shunt insertion that necessitate the modification in the hardware of valve or insertion technique to decrease the risk of CSF over the drainage.

Surgical management of laryngeal bilateral abductor palsy: comparative study between carbon dioxide and diode lasers

This study aims to compare the results of both CO2 laser and diode laser combined arytenoidectomy with posterior cordectomy in managing patients with bilateral vocal fold paralysis. A prospective study involved 80 bilateral vocal cord immobility patients in adduction. They are divided into two groups according to the laser used, whether CO2 (with a wavelength of 10.6 µm) or diode (with a wavelength of 980 nm). We used mMRC (Modified Medical Research Council) dyspnea scale to assess dyspnea in our patients, while the voice was evaluated by both maximum phonation time and the voice handicap index. Quantitative variables were described using means and standard deviations, while categorical variables were described using frequencies and were compared using the chi-square test, Fisher exact test, and Monte Carlo test. There was a statistically non-significant difference between the studied groups regarding mMRC dyspnea scale and Voice Handicap Index preoperatively and postoperatively. There is a statistically significant difference between the two groups regarding maximum phonation time postoperatively (significantly higher in the CO2 laser group) (p < 0.001). The CO2 laser and diode laser could be used safely for the management of bilateral vocal cord paralysis. The CO2 laser maintains better voice parameters and less postoperative pain, while the diode laser gives less operative time, lower cost, and simplicity of use.

088 The clue is in the neck

Miller-Fisher Syndrome is characterised by ataxia, ophthalmoplegia and areflexia. Approximately 72% are preceded by infection, of which, Campylobacter jejuni and Haemophilus influenzae are frequently reported aetiological agents.We report a 22-year-old lady admitted with ataxia and worsening diplopia. On examination, she had bilateral abducens nerve palsies, left-sided facial weakness and widespread areflexia. Palpable lym- phadenopathy was present bilaterally.MRI showed mild inflammatory sinus disease and marked cervical lymphadenopathy. CSF revealed albuminocytologic dissociation and monospot was positive for Epstein-Barr virus. Subsequent abdominal sonography detected splenomegaly and counselling on avoiding contact sports was provided.A diagnosis of MFS was made based on the history, clinical features and supportive investigations. Anti-GQ1b antibodies were negative.MFS is typically associated with anti-GQ1b antibodies although a significant percentage (&gt;10%) are seronegative. Recent studies have suggested anti-GAD may be associated with a broader clinical spectrum of presentations.The patient received 5 days of intravenous immunoglobulin and several weeks later she had complete symptomatic resolution.MFS is a self-limiting, though temporarily debilitating condition, and EBV should be remembered as a causative agent; particularly in susceptible demographic groups.Radiographic and viral clues, including examination of the neck, may facilitate accurate diagnosis.jkcleaver88@gmail.com

Lemierre's syndrome complicated by cerebral venous sinus thrombosis: A life threatening and rare disease successfully treated with empiric antimicrobial therapy and conservative approach.

Lemierre's syndrome (LS) is a "forgotten" condition characterized by septic thrombophlebitis of the jugular vein that follows an otolaryngological infection. Fusobacterium necrophorum is the aetiological agent responsible for the syndrome in adolescents and young adults whereas in older people even common bacteria are involved. Complications arise from spreading of septic emboli distally, i.e. to the brain, lungs, bones and internal organs everywhere in the body. We report a middle-aged woman who presented with headache and bilateral sixth cranial nerve palsy following a sphenoidal sinusitis and left mastoiditis. Imaging revealed thrombotic involvement of the left internal jugular vein as well as of several cerebral venous sinuses thrombosis (CVT). Currently, precise management protocols of LS with CVT complication do not exist although a combination of macrolides and second or third-generation cephalosporins, as well as anti-coagulants represent the mainstream of therapeutics. Surgical drainage is associated to remove septic foci but is burdened by severe complications and side effects. Complete recovery was achieved following pharmacological treatment in our patient. This report adds further evidence that LS complicated by CVT may be effectively treated adopting a conservative approach thus avoiding surgical drainage and severe complications.

Gummatous neurosyphilis in an elderly patient in the Australian outback: a case report

IntroductionNeurosyphilis is an infection caused by the spirochete Treponema pallidum, which causes infiltration and thickening of brain meninges. Despite being an Old World disease, the rates of infection continue to rise. This clinical challenge involves early and accurate diagnosis, as neurosyphilis masquerades with various clinical symptoms and is often missed during initial presentation to the hospital. A comprehensive history and clinical examination are essential to detect suspicious cases early for further cerebrospinal fluid examination and neuroimaging. Patients treated with benzylpenicillin for a specific duration often show promising clinical and cognitive improvement, thus emphasizing the need for constant vigilance in our day-to-day practice.Case presentationA 77-year-old Caucasian gentleman presented to our hospital repeatedly with multiple episodes of presyncope and cognitive impairment. He also demonstrated bilateral deafness, tabes dorsalis, and left sixth cranial nerve palsy. His cerebrospinal fluid examination showed a nonreactive venereal disease research laboratory test, and magnetic resonance imaging of the brain revealed a gumma.ConclusionThe diagnosis of neurosyphilis in the elderly requires a combination of clinical vigilance and a high index of suspicion, along with multimodal investigations, including cerebrospinal fluid examination and brain imaging.