Hypoglossal Palsy Research Articles

Severe blood pressure elevation following ephedrine administration during carotid endarterectomy under general anesthesia: A CARE-compliant case report.

During carotid endarterectomy (CEA) surgery, blood pressure management is particularly important to prevent cerebrovascular and cardiac complications. Ephedrine is a commonly used vasopressor, however, we report the case of a patient with unusually severe blood pressure elevation following intravenous ephedrine administration during CEA. A 72-year-old man diagnosed with right proximal internal carotid artery stenosis underwent CEA under general anesthesia. After declamping the common carotid artery, blood pressure rapidly increased by 125 mm Hg (from 90 to 215 mm Hg) after ephedrine (4 mg) was administered, but the heart rate was stable. There was an ordinal increase in blood pressure after the same small dose of ephedrine was administered at the early stage of the surgery. And the surgical approach was difficult because he had a high location of carotid bifurcation and a prominent mandibular angle. Because of the anatomical proximity of the cervical sympathetic trunk to the carotid bifurcation and the particularly complicated surgical process in the present case, we postulate the reason for this adverse reaction as transient sympathetic denervation supersensitivity. Perdipine (0.5 mg) was administered repeatedly to reduce blood pressure. After surgery, he was diagnosed with right hypoglossal nerve palsy, and no other abnormal signs were found. This case highlights the need for caution in the use of ephedrine, which is commonly used in CEA surgery, wherein blood pressure management is particularly important. Although it is a rare and unpredictable case, α-agonists are considered safer in situations where sympathetic supersensitivity is possible.

Hypoglossal nerve palsy following spine surgery in Klippel-Feil syndrome patient

Panzone, John BS; Lavelle, William MD, MBA; Tallarico, Richard A. MD Author Information

Cervical Internal Carotid Artery Cystic Aneurysm Presenting With Hypoglossal Nerve and Vagus Nerve Palsy.

Cervical Internal Carotid Artery Cystic Aneurysm Presenting With Hypoglossal Nerve and Vagus Nerve Palsy.

A CADAVERIC STUDY OF NILA-MANYA MARMA

Background: The Marma Sharira is one of the most explored parts of Rachana Sharira. The Nila and Manya marma are located in greeva (neck region), 4 in number, vaikalyakara in nature. Traumatic effect on these marma produces mukata or dumbness/ inability to speak, swaravaikrita or hoarseness of voice and rasagrahita or incapacity to perceive taste (hypogeusia or ageusia). Aims and objective: To assess the location and structural composition of Nila and Manya marma. Material and methods: One cadaver was taken for dissection in the P.G. Department of Rachana Sharir, Sri Ganganagar College of Ayurvedic Science and Hospital, Rajasthan. The surrounding area of Nila and Manya marma was dissected and observe the anatomical structures. Discussion: After proper dissection following neurovascular structures were seen common carotid artery (CCA), which was bifurcated into the external and internal carotid artery, vagus nerve, and internal jugular vein (IJV). Injury to Nila and Manya marma can produce mukata or dumbness/ inability to speak, swaravaikrita or hoarseness of voice and rasagrahita or incapacity to the perception of taste (hypogeusia or ageusia). Hypoglossal nerve palsy due to spontaneous internal carotid artery dissection leads to vocal cord paralysis and hoarseness of voice. Conclusion: After a proper analysis of the nature of Nila and manya marma, it can be concluded that Nila marma can be considered the right and left internal jugular vein, and Manya marma as the right and left carotid artery.

Dural Arteriovenous Fistula with Hypoglossal Nerve Paralysis

A male in his early 30s presented with a swelling just below the angle of his left mandible for the last 2 months. The swelling had insidious onset, progressive and painless. Examination found 4 × 4cm, diffuse, soft to firm, pulsatile swelling in the upper part of the neck on left side ([Fig. 1]). An oral examination revealed left hypoglossal nerve paralysis. Further examination was noncontributory, including vagus and accessory spinal nerve examination. A probable diagnosis of carotid body tumor was kept, and the patient was subjected to computerized angiography. Angiography revealed dural arteriovenous fistula (DAVF), a rare clinical entity leading to hypoglossal nerve paralysis ([Figs. 2 (A, B)]). Patient was advised to undergo digital subtraction angiography for further management, but he refused and chose conservative care with regular follow-up.

Managing Multiple Schwannomatosis of Vagus and Hypoglossal Nerves: The Unanticipated Complications.

Schwannomas are rare benign tumours of the nerve sheath. Extracranial schwannomas are usually found solitary, in the absence of other features of neurofibromatosis. The non NF1/2 multiple schwannomas are collectively described as the clinical scenario called schwannomatosis. We present a rare case of two extracranial schwannomas involving vagus and hypoglossal nerves in a 22-year-old female along with an unusual surgical complication of CSF leak presenting as post-op neck mass and a review of previously reported similar cases. A thorough literature search using the MeSH terms-'schwannomatosis' or 'Multiple Schwannoma' and 'Vagal Schwannoma' and 'Hypoglossal Schwannoma', was conducted using online databases and augmentated by hand search. A total of 13 reported cases were found and reviewed. Of the 14 cases described from review of literature and our case, 50% had involvement of vagus nerve as one of the components. 12.5% had hypoglossal and cervical sympathetic plexus involvement each. All patients underwent surgical excision. Half of the patients suffered intraoperative nerve sacrifice with resultant severe functional deficits like vocal cord paralysis, Horners syndrome, hypoglossal palsy, facial palsy and eleventh nerve palsy. In our case, there was un-unusual complication of CSF leak presenting as a cervical neck mass. Multiple extracranial head and neck schwannomas are rare and their management is fraught with several complications. Decision to operate is often perplexing. However, early planned surgical excision and preservation of nerve of origin minimizes the impact on quality of life postoperatively.

A taxonomy for brainstem cavernous malformations: subtypes of medullary lesions.

Medullary cavernous malformations are the least common of the brainstem cavernous malformations (BSCMs), accounting for only 14% of lesions in the authors' surgical experience. In this article, a novel taxonomy for these lesions is proposed based on clinical presentation and anatomical location. The taxonomy system was applied to a large 2-surgeon experience over a 30-year period (1990-2019). Of 601 patients who underwent microsurgical resection of BSCMs, 551 were identified who had the clinical and radiological information needed for inclusion. These 551 patients were classified by lesion location: midbrain (151 [27%]), pons (323 [59%]), and medulla (77 [14%]). Medullary lesions were subtyped on the basis of their predominant surface presentation. Neurological outcomes were assessed according to the modified Rankin Scale (mRS), with an mRS score ≤ 2 defined as favorable. Five distinct subtypes were defined for the 77 medullary BSCMs: pyramidal (3 [3.9%]), olivary (35 [46%]), cuneate (24 [31%]), gracile (5 [6.5%]), and trigonal (10 [13%]). Pyramidal lesions are located in the anterior medulla and were associated with hemiparesis and hypoglossal nerve palsy. Olivary lesions are found in the anterolateral medulla and were associated with ataxia. Cuneate lesions are located in the posterolateral medulla and were associated with ipsilateral upper-extremity sensory deficits. Gracile lesions are located outside the fourth ventricle in the posteroinferior medulla and were associated with ipsilateral lower-extremity sensory deficits. Trigonal lesions in the ventricular floor were associated with nausea, vomiting, and diplopia. A single surgical approach was preferred (> 90% of cases) for each medullary subtype: the far lateral approach for pyramidal and olivary lesions, the suboccipital-telovelar approach for cuneate lesions, the suboccipital-transcisterna magna approach for gracile lesions, and the suboccipital-transventricular approach for trigonal lesions. Of these 77 patients for whom follow-up data were available (n = 73), 63 (86%) had favorable outcomes and 67 (92%) had unchanged or improved functional status. This study confirms that the constellation of neurological signs and symptoms associated with a hemorrhagic medullary BSCM subtype is useful for defining the BSCM clinically according to a neurologically recognizable syndrome at the bedside. The proposed taxonomical classifications may be used to guide the selection of surgical approaches, which may enhance the consistency of clinical communications and help improve patient outcomes.

Hypoglossal nerve palsy after SARS-CoV-2 vaccination – report of two cases

BackgroundSARS-CoV-2 vaccination is associated with an increased risk for Bell’s palsy and some other neurological disorders assumed to be of autoimmune origin. While facial nerve palsy is frequent and usually idiopathic, hypoglossal nerve palsy is rare, and a specific cause is almost always found. We firstly report two patients who developed isolated hypoglossal nerve palsy shortly after SARS-CoV-2 vaccination.Case presentationTwo otherwise healthy patients, a 49-year-old man and a 39-year-old woman, developed unilateral hypoglossal nerve palsy 10 and 7 days after the second SARS-CoV-2-vaccination (AstraZeneca and BioNTech/Pfizer), respectively. In both subjects, needle electromyography showed denervation and rarefication of motor units. CT, MRI, examination of blood and CSF as well as ENT exam were unremarkable. In both subjects symptoms gradually improved.ConclusionDue to close temporal relationship, the absence of other etiologies, and spontaneous improvement we suspect the vaccination as the cause for hypoglossal nerve palsy in both patients. This is further supported by the rarity of isolated hypoglossal nerve palsies, especially in idiopathic cases. We suggest the addition of hypoglossal nerve palsy to the list of neurological injuries potentially caused by SARS-CoV-2 vaccination.

Hypoglossal Nerve Palsy Due to a Sublingual Space Abscess

We report an unusual case of a hypoglossal nerve palsy secondary to a sublingual space abscess in a previously fit and healthy 59-year-old man. The patient presented with fever, dysphagia, trismus, and a left-sided tongue and floor-of-mouth swelling with left hypoglossal nerve palsy. Computed tomography (CT) scan revealed a 3.5-cm abscess of the left sublingual space. The abscess drained spontaneously while awaiting surgery with resolution of symptoms. Urgent investigation with CT is recommended for every deep neck space infection. Hypoglossal nerve palsy is a rare sign that warrants further investigation to exclude malignancy.

New-Onset Tongue Weakness Due to Skull Base Metastases to Bilateral Hypoglossal Canals

Hypoglossal nerve palsy is a rare disorder resulting in dysarthria and tongue weakness, usually caused by direct nerve compression or injury. Malignant invasion of the skull base can rarely lead to bilateral hypoglossal nerve compression at the exit of the hypoglossal canals. We report the case of a 40-year-old man with stage IV colorectal cancer who presented with tongue weakness and dysphagia and was discovered to have new metastases to his skull base with invasion of his bilateral hypoglossal canals.

Congenital Anonychia with Brachydactyly with Novel, Unilateral Congenital Hypoglossal Nerve Palsy and Staghorn Renal Calculus

Abstract Congenital anonychia is a relatively rare abnormality of nail development affecting all or some of the finger and toe nails, characterized by either complete absence of nails or hypoplasia of nails. We report a rare case of congenital anonychia with brachydactyly with unique congenital abnormalities of heart-shaped tongue, congenital hypoglossal nerve palsy, and staghorn calculus. To our knowledge, these associations have never been described before and do not fall under any known syndromic entity.

Cone-beam CT-assisted microcatheter tip placement at the shunted pouch entry zone: A technical note for anterior condylar arteriovenous fistula.

Accurate microcatheter placement for anterior condylar arteriovenous fistula (AVF) enables selective transvenous embolization (TVE) and helps to avoid hypoglossal nerve palsy. Anterior condylar AVF has a shunted pouch within the condylar vascular and osseous structures. Detailed anatomical comprehension of the shunted pouch is essential, in addition, we believe that it is important to have a strategy for where in the shunted pouch to start filling with coils. Specifically, we consider that it is important to structurally understand the more upstream location (arterial side) within the shunted pouch (called "shunted pouch entry zone"), guide the microcatheter there, and embolize from that site. Although several studies have discussed the usefulness of intraoperative cone-beam computed tomography (CBCT) for treating anterior condylar AVF, there are no studies which have mentioned the importance of microcatheter position before coil embolization in selective TVE as in this study. Intraoperative localization of the shunted pouch entry zone is often difficult. Herein, the authors report that cone-beam computed tomography (CBCT) can assist accurate microcatheter tip placement at the shunted pouch entry zone before staring embolization. This is the novel application of intraoperative CBCT to treat anterior condylar AVF successfully treated with precise and selective TVE.

Is Revascularization of V1 Segment of Vertebral Artery Combined with Ipsilateral Carotid Endarterectomy Safe?

The recommendation of the European Society for Vascular Surgery (ESVS) is that vertebral revascularization combined with ipsilateral CEA (carotid endarterectomy) should not be performed in the same operation. ESVS believes that vertebral revascularization combined with ipsilateral CEA increases perioperative death/stroke rates. In our opinion, revascularization of the first segment of vertebral artery (V1) combined with ipsilateral CEA is safe compared to vertebral V1 revascularization in the perioperative period. The purpose of this study is to prove that revascularization of V1 segment of vertebral artery combined with ipsilateral CEA is secure in the perioperative period. We describe our experience with homochronous revascularization of V1 segment of vertebral artery with ipsilateral CEA (group B) and simple revascularization of V1 segment of vertebral artery (group A) in 48 consecutive patients during a 5-year period. O.Y. (Ouyang) incisions were used in both groups. We compare the results of the 2 procedures with aspects of mortality, stroke, morbidity, incident rates of complications, and so on. There was no significant difference between patients in group A and group B in terms of red blood cell reduction, postoperative ventilator using time, postoperative drainage volume, postoperative drainage days, postoperative hospitalize duration, and incident rates of postoperative complications. The postoperative complications include death, stroke, Horner syndrome, vocal paralysis, hypoglossal nerve paralysis, wound hematomas, and lymphatic leakage. Revascularization of vertebral artery combined with ipsilateral CEA should be divided into revascularization of V1 segment of vertebral artery combined with ipsilateral CEA and revascularization of V3 segment of vertebral artery with ipsilateral CEA. Revascularization of V1 segment of vertebral artery combined with ipsilateral CEA is safe; it can be performed for suitable patients who are fit for indications. O.Y. incisions can fully expose the target blood vessels and simplify the procedures without transecting the sternocleidomastoid muscles in operations.

Skull base osteomyelitis: a rare but life-threatening illness

A 72-year-old man with type 2 diabetes was admitted to a hospital in Japan with a 2-month history of repeated falls and 1-month history of persistent severe headache. He had an unsteady gait, dysarthria, and dysphagia due to bilateral hypoglossal nerve palsy. Contrast-enhanced CT showed an ill-defined, poorly enhanced mass in the posterior wall of the nasopharynx that surrounded the bilateral internal carotid arteries (figure), with clival bone destruction. On T1-weighted MRI, high signal intensity of the bone marrow fat of the clivus was not present. Contrast-enhanced T1-weighted image and diffusion-weighted image on MRI added no further clarification. Massive bone destruction on CT and loss of bone marrow on MRI led to a suspected diagnosis of nasopharyngeal carcinoma.

Bilateral palsy of the hypoglossal nerve following general anesthesia for emergency surgery. A case report

Introduction and importanceHypoglossal nerve palsy is a rare condition usually associated with tumors, trauma, stroke or multiple sclerosis. It can be associated with other cranial nerve palsies while injury to this nerve typically affects a patient's articulation by causing lingual motility disturbance and swallowing difficulty. Bilateral isolated hypoglossal nerve palsy is an even more infrequent condition, which can occasionally be due to airway manipulation.Case presentationWe describe a case of bilateral hypoglossal nerve damage following general anesthesia for emergency surgery, presenting with dysarthria, immobility of the tongue and dysphagia after extubation. The patient had a gradual recovery of all lost functions during the next four months.Clinical discussionBilateral hypoglossal nerve palsy is a very rare entity and tracheal tube malposition or prolonged but unnoticed tracheal cuff pressure especially in the face of low blood pressure, should be considered as possible causative mechanisms for this condition. This underlines the importance of careful positioning of the patient's head and neck during surgery as well as the meticulous and correct performance of routine maneuvers of airway management.ConclusionBilateral hypoglossal nerve palsy is a very rare entity. Diagnosis and management of twelfth nerve palsy require a multidisciplinary approach to achieve the best patient outcome.

107 Tapia’s syndrome – is the mechanism neuropraxia from intubation or is it more complex?

An otherwise well 23 year old lady had a septorhinoplasty with bilateral implants under general anaesthesia for nasal blockage and right sided nasal deviation.The operation was successful but six hours later the left side of her tongue felt odd, she had dysphonia and ‘it felt funny to swallow’. She had deviation of the tongue to the left on protrusion; couldn’t quickly it it from side to side; and the sensation on its left side was altered. There wasn’t obvious tongue swelling or haematoma and no weakness or numbness in the face or limbs. Naso-endoscopy confirmed a left vocal cord paralysis.This was recognised as a left sided hypoglossal and vagal nerve palsy. The ENT and anaesthetic teams, felt that it might have been due to over-packing of the throat causing compression and neuropraxia. Her symptoms substantially improved after 5 days with a course of dexamethasone.This case will be discussed with reference to both the first described and more recent case reports of Tapia’s syndrome along with the hypothesised mechanisms of injury. Tapia’s syndrome is a thought to be due to pressure during intubation but most case reports follow surgeries with hammering and other sudden applications of force, rather than in emergency situations which would be expected to have more problems resulting from intubation. It seems important that those who resuscitate patients are aware of this potential complication.hut898@gmail.com

Major traumatic injury sustained during use of a virtual reality (VR) headset

We report the first documented case of significant, potentially life-changing trauma sustained during use of virtual reality (VR). A male in his fifties fell from standing whilst immersed in a VR game and sustained injuries including bilateral occipital condyle fractures, spinal cord contusion resulting in central cord syndrome, right vertebral artery occlusion, and left hypoglossal nerve palsy. His injuries were managed conservatively with a lengthy recovery period. The patient made a good recovery with full resolution of his symptoms and has returned to full-time employment. This case discusses how these injuries are commonly related and considers the implications of VR on a person’s balance and whether the headset may make neck extension injuries more likely.

Highest Resolution MicroCT Scan of the Human Brainstem Reveals Putative Anatomical Basis for Infrequency of Medial Medullary Syndrome

Posterior circulation or brainstem strokes account for approximately 25% of acute strokes, affecting arterial territories in the medial or lateral divisions of the midbrain, pons, or medulla. Out of all brainstem regions, medial medullary strokes are the rarest, making up fewer than 1% of reported posterior circulation cases. Medial Medullary Syndrome (MMS) is a clinical triad of contralateral hemiplegia, loss of fine touch / position sense, and hypoglossal palsy that may result from ischemia or hemorrhage of small perforating branches of the anterior spinal, vertebral, or basilar arteries. The relative infrequency of MMS is surprising given the prevalence of stroke in other perforator artery territories as these vessels are more susceptible to small vessel disease. Indeed, small perforator‐type vessels from other parent arteries contribute to more than 50% of all strokes in a population (e.g. lacunar branches of the middle cerebral artery and paramedian pontine branches of the basilar artery). This disparity in prevalence remains unexplained in part because clinical anatomy has been historically limited by an unfavorable ratio of fine blood vessel size to coarse MRI and CT scan resolution. Here, we capture and digitally dissect the highest‐ever‐resolution diffusible iodine‐based contrast‐enhanced CT (diceCT) scanned images of a cadaveric brainstem to map MMS arteries in never‐before‐captured detail. A cadaveric brain was fixed in formalin and stained using a 3% concentration of Lugol’s iodine (I2KI) for 12.5 weeks (refreshed every 2 weeks), before microCT scanning at 57 microns (a scale twice as fine as any previous scans). The resulting image stack was segmented in Avizo 2020.1. Results show that within the MMS anterior spinal artery territory, there are numerous, small sulcal artery branches perforating the medulla within the anterior median fissure. These branches proceed in parallel through the anteroposterior depth of the medulla as expected; however, we also identify a network of intraparenchymal, rostrocaudal anastomoses between these sulcal perforating branches. This network of intraparenchymal sulcal artery anastomoses has never been described, and may provide a significant collateral supply of oxygenated blood flow throughout the medial medulla. By ramifying deeper tissues, this anastomosis can help explain the infrequency of MMS.

Microvascular Decompression for Hypoglossal Nerve Palsy Associated With Vertebral Artery: Case Report and Review of Literature

BACKGROUND AND IMPORTANCE: Hypoglossal nerve palsy is an infrequent condition that could be rarely caused by compression from nearing vasculature. Hypoglossal nerve palsy associated with vertebral artery (VA) is rarely reported. There are less than 15 cases of such conditions in the literature. CLINICAL PRESENTATION: We present a 17-year-old boy suffering from dysarthria, chewing disability, a tingling sensation, and deviation of the tongue to the right from 6 months ago. After a thorough examination, MRI was performed with clinical suspicion of hypoglossal nerve palsy, and the result showed an ectatic VA pressing against the right hypoglossal nerve. He underwent microvascular decompression surgery. On follow-up visits, he showed gradual improvement of symptoms. CONCLUSION: In cases of cranial nerve palsies, compression by adjacent vasculature should be considered as a differential diagnosis and microvascular compression should be considered as a safe definitive treatment.

Godtfredsen syndrome \u2013 recurrent clival chondrosarcoma with 6\u2009years follow up: a case report and literature review

BackgroundWe report a rare case of Godtfredsen syndrome caused by clival chondrosarcoma and perform a review of literatures. This article also explains the clinico-anatomical correlation of this rare neurological syndrome.Case presentationA 22-year-old gentleman presented with binocular diplopia. Clinical examination revealed an isolated right abducent nerve and right hypoglossal nerve palsy, with other cranial nerves intact.Neuroimaging revealed a right clival mass. Supraorbital craniotomy and tumour debulking were done in the same year. Histopathological examination showed low-grade chondrosarcoma.After 5-years of default, he came back with the tumour enlarged. He underwent a right orbitozygomatic craniotomy and tumour excision with 33 cycles of radiotherapy.Despite two surgeries and radiotherapy, the abducent nerve and hypoglossal nerve did not improve throughout 6 years of follow-up. Cranial nerve VI palsy is not always a false localizing sign, in Godtfredsen syndrome it serves as a localizing sign.ConclusionTo the best of our knowledge, this is the first case report of Godtfredsen Syndrome secondary to clival chondrosarcoma. Cranial nerve VI and XII palsy with no involvement of other cranial nerves, most likely the pathology is located at the clivus.