Left Abducens Nerve Palsy Research Articles

Idiopathic hypertrophic cranial pachymeningitis

Idiopathic hypertrophic cranial pachymeningitis is a rare chronic inflammatory process of unknown origin that can cause neurological deficits owing to thickening of the dura. Patients with this condition commonly present with cranial neuropathy accompanied by localized headache. The clinical features, neuroimaging findings, histopathological features and treatment outcomes for three patients with this condition are reported here. The first patient presented with subacute dull headache in the left temporal area followed by left abducens nerve palsy. The second patient suffered from a cranial nerve IX–XII lesion accompanied by an occipital headache and the third patient presented with left optic neuropathy and mild headache in the frontal area. In all patients, MRI of the brain revealed prominent dural thickening, and histopathological study of the dura revealed chronic inflammatory cell infiltration. Combined therapy with corticosteroid and immunosuppressive drugs was effective, resulting in almost complete resolution of the symptoms and signs, except for visual impairment in one patient.

Application of high-definition flexible neuroendoscopic system to the treatment of primary pineal malignant B-cell lymphoma

Background Endoscopic procedure for pineal region tumors and associated hydrocephalus has been getting more standard. We applied high-definition flexible neuroendoscopic system to the initial management of primary pineal malignant B-cell lymphoma. Efficacy of this new technology as an initial treatment of pineal region tumors is discussed. Case Description A 31-year-old man presented with progressive left abducens nerve palsy with headache and nausea. Magnetic resonance imaging showed multiple enhanced lesions in several cranial nerves and obstructive hydrocephalus due to a pineal cystic lesion with nodular enhancement on its roof. Diagnostic endoscopic biopsy of the pineal region tumor and ETV were performed using new flexible endoscopic system, in which a small CCD camera is implanted at the tip of the flexible scope, without complications. The thin cyst membrane was perforated and then opened with endoscopic forceps. A biopsy of the solid nodule on the cyst wall was carefully performed without injuring the surrounding venous system. We found a lot of small wartlike lesions along the third ventricular wall and fish egg–like abnormal lesions adhered to the colloid plexus around the pineal region, which were considered to be associated with dissemination. These lesions were not apparent in initial MRI. Histopathologic diagnosis of the pineal region tumor was malignant B-cell lymphoma. Conclusion Endoscopic biopsy and ETV for pineal region tumors can be safely achieved using a high-definition flexible neuroendoscopic system. Moreover, this system allowed us to observe disseminated lesions that are not revealed by preoperative neuroradiologic studies, which might enable us to make staging diagnosis of the disease.

Abducens Nerve Palsy Induced by Chemotherapeutic Agents

Purpose: To report two cases of abducens nerve palsy that occurred after the administration of chemotherapeutic agents. Case summary: (Case 1) A 49-year-old woman with breast cancer presented with acute onset of diplopia 6 weeks after the beginning of combination chemotherapy with cyclophosphamide, doxorubicin, and paclitaxel. She had a left esotropia of 30 prism diopters (PD) with a mild decrease in abduction of the left eye. She was diagnosed with left abducens nerve palsy. (Case 2) A 29-year-old man with non-Hodgkin’s lymphoma presented with diplopia 7 weeks after beginning combination chemotherapy including cyclophosphamide, adriamycin, vincristine, and prednisolone. He had a 20PD esotropia in the primary position with a slight decrease in abduction of both eyes. He was diagnosed with bilateral abducens nerve palsy. The chemotherapy regimen of both patients was changed, and they were followed up without treatment. In case 1, diplopia improved 2 months after change of chemotherapy regimen with complete recovery within 4 months. In case 2, diplopia improved 2 months after a change of chemotherapy regimen with complete recovery within 3 months.

Diffuse large B-cell non-Hodgkin’s lymphoma associated with bilateral carotid-cavernous fistulas in an elderly woman

An 74-year-old woman presented with a 2-month history of left proptosis, left eye chemosis, left abducens nerve palsy and cervical lymphadenopathy. She was noted to have bilateral carotid cavernous fistulas and was treated with transvenous coil embolization. The diagnosis of diffuse large B-cell non-Hodgkin’s lymphoma was only confirmed 4 months later, despite a high index of suspicion, after clinical deterioration. This is, to our knowledge the first reported case of non-Hodgkin’s lymphoma associated with bilateral carotid cavernous fistulas.

Intracranial solitary juvenile xanthogranuloma successfully treated with stereotactic radiosurgery

Juvenile xanthogranuloma (JXG) is a non-Langerhans cell histiocytosis, which primarily affects the skin in young children. Although intracranial involvement is rare, it differs from other systemic JXG because its responsiveness to non-surgical treatment is poor. We present the case of a 2-year-old boy with left abducens nerve palsy. Imaging studies revealed a mass in the left Meckel's cave. Systemic examination showed no other abnormalities including his skin. After partial removal, JXG was diagnosed based on immunohistochemical evaluation. He underwent a stereotactic radiosurgery. Then, the mass decreased, and his abducens nerve palsy improved. This is the seventh case with isolated intracranial JXG, and the first case to be treated with radiosurgery. We consider that stereotactic radiosurgery is an excellent choice for treatment of intracranial JXG.

Isolated Sixth Cranial Nerve Palsy in Preeclampsia

Isolated Sixth Cranial Nerve Palsy in Preeclampsia

Sudden Death from Pituitary Apoplexy in a Patient Presenting with an Isolated Sixth Cranial Nerve Palsy

A 68-year-old diabetic, hypertensive man presented with a left sixth cranial nerve palsy. MRI demonstrated an inhomogeneous sellar mass encroaching on the left cavernous sinus. Two days later, a left third cranial nerve palsy developed. Within 24 hours, the patient went into cardiac arrest and died. An autopsy showed hemorrhage within a pituitary macroadenoma ("pituitary apoplexy"). Pituitary apoplexy should be considered a cause of acute isolated sixth cranial nerve palsy and may represent a life-threatening emergency that can be averted with emergent hormonal replacement and hypophysectomy.

Character changes from idiopathic cranial pachymeningoencephalitis

A 66-year-old man with idiopathic cranial pachymeningoencephalitis was described. He suffered from left orbital pain, and character changes. He became short tempered, and was very attached to trifles. Two years prior to these symptoms, he had developed transient left abducent nerve palsy. Head MRI showed a thickening and enhancement of the dura mater on gadolinium-enhanced T1-weighted images, and high signal intensity lesions at bilateral frontal lobes predominantly in the white matter on T2-weighted images. Biopsies revealed microglial proliferation in the cerebral parenchyma, and mild lymphocytic perivascular infiltration. No evidence of intracranial infection was detected. We therefore treated him with methylprednisolone pulse therapy followed by oral prednisolone. His character became gradually normalized, and bilateral frontal lobe lesions seen on MRI disappeared. This is the first case to describe recurrent pachymeningoencephalitis with character changes, and symptoms were probably due to frontal lobe dysfunction.

Abducens nerve palsy and optic neuritis as initial manifestation in brucellosis

Cranial nerve involvement in brucellosis is rare. We present a case of brucellosis presenting with optic neuritis and abducens nerve palsy on the left side. Cerebrospinal fluid findings indicated Brucella meningitis with high protein count, low sugar level and pleocystosis. In addition, Brucella agglutination test (Wright test) was found to be 1/128 in cerebrospinal fluid. Serum agglutination test for Brucella was also positive at 1/1280. This case was diagnosed as brucellosis involving optic and abducens nerves. The patient was treated by ceftriaxone (intravenous), rifampicin (orally) and doxycycline (orally). Two months later the patient's vision acuity in the left eye had moderately improved and the patient's left abducens palsy had almost disappeared. In conclusion, cranial nerve involvement in brucellosis can have good prognosis if anti-Brucella treatment is undertaken early.

Left Sixth Cranial Nerve Palsy with Herpes Zoster Ophthalmicus

This man reported acute left retro-orbital pain of one week's duration. Three days later, double vision developed.

Sixth Cranial Nerve Palsy Caused by Compression From a Dolichoectatic Vertebral Artery

A 68-year-old man had an unremitting left sixth cranial nerve palsy immediately after completing a long bicycle trip. High-resolution (3 Tesla) magnetic resonance imaging disclosed a dolichoectatic vertebral artery that compressed the left sixth cranial nerve against the belly of the pons at its root exit zone. It was postulated that increased blood flow in the vessel during the unusually prolonged aerobic exercise precipitated the palsy. Compressive palsies of cranial nerves caused by a dolichoectatic basilar artery have often been documented; compressive palsy caused by a dolichoectatic vertebral artery is less well-recognized.

Isolated Bilateral Abducens Nerve Palsies Due to Metastasis to the Clivus from Adenocarcinoma in the Lung

Isolated bilateral abducens nerve palsies due to clivus tumor have rarely been reported. We report on a 71-year-old woman with isolated bilateral abducens nerve palsies probably caused by metastatic clivus tumor from an adenocarcinoma in the lung. She complained of diplopia due to right abducens nerve palsy. Two weeks later, left abducens nerve palsy also appeared. Cranial magnetic resonance imaging showed a gadolinium-enhanced lesion in the clivus. Computed tomography of the chest demonstrated a lesion in segment 9 of the left lung. Biopsy of this lesion confirmed adenocarcinoma. When we encounter isolated bilateral abducens nerve palsies, clivus tumor, including metastasis from lung carcinomas, should be considered.

Isolated Abducens Nerve Palsy Associated with Retinoic Acid Therapy: A Case Report

Isolated abducens nerve palsy is a rare complication of treatment with various drugs. Here, the authors report the case of a 23-year-old female with isolated left abducens nerve palsy after long-term retinoic acid therapy. The association is based on the temporal relationship and the exclusion of other possible etiologic factors following extensive laboratory and imaging diagnostics. The authors suggest that isolated abducens nerve palsy may be a presenting sign of a toxic neuropathy associated with retinoic acid therapy. After the exclusion of other organic lesions, especially idiopathic intracranial hypertension, and an assessment of the risk-benefit ratio, discontinuation of treatment must be considered in such cases.

Intracranial hypertension as an initial manifestation of spinal neuroectodermal tumor

A 19-year-old girl had headaches, blurred vision and vomiting for 2 weeks. Neurological examination revealed only bilateral papilloedema and left abducens palsy. Neuroimaging of the brain was normal. Cerebrospinal fluid study showed intracranial hypertension (IH), hypoglycorrhachia, hyperproteinorrhachia, and a negative cytology study. Eight months after the onset, paraparesis occurred. Spinal magnetic resonance imaging showed intramedullary masses at the cervical and thoracic cords with extensive seeding. Biopsy of the mass showed primitive neuroectodermal tumor (PNET). IH rarely occurs in patients with spinal cord neoplasms. Its incidence is low and the condition is always associated with signs of myelopathy. We report a patient whose initial manifestation of spinal PNET was IH only. Spinal tumor should be considered in IH patients whose intracranial examinations are negative.

Diagnosis

A noncontrast head computed tomography (CT) scan showed slight narrowing of the ventricles and mild left-sided edema. A magnetic resonance imaging scan revealed a cavernous sinus thrombosis (Figure 2). The patient was admitted and treated with intravenous antibiotics and heparin. Magnetic resonance imaging with gadolinium is the diagnostic test of choice for detection of cerebral venous thrombosis because thrombi can be visualized. CT scans are often abnormal but nonspecific. The most common CT findings are small ventricles and edema; results of CT scans are abnormal but nonspecific in up to 80% of patients. Images in emergency medicineAnnals of Emergency MedicineVol. 44Issue 5PreviewA 42-year-old, previously healthy man presented to the emergency department complaining of a progressive headache behind his left eye for 3 days. He was well until 3 weeks earlier when he developed a persistent nasal discharge and low-grade fever. The day of presentation, he developed double vision, became nauseated, and vomited twice. At presentation, he had a temperature of 100.4°F (38.0°C) and tenderness over the maxillary and frontal sinuses. Ophthalmologic examination revealed marked chemosis of his left eye, a fixed and dilated left pupil, a left abducens nerve palsy, and bilateral papilledema (Figure 1). Full-Text PDF

Multineuropathy in a patient with HBV infection, polyarteritis nodosa and celiac disease

A 53‐year‐old man came to our observation for impaired gait and painful paresthesia in his hands and feet. Three years before he suddenly presented tingling in his hands, followed, after a few months, by paresthesia in his feet, weakness of the right hand and foot and cutaneous erythema. Nearly one year after the onset, he presented left abducens nerve palsy that completely resolved in three months with steroid therapy. The patient's conditions progressively worsened and when he was admitted to our clinic the neurological examination revealed a stepping gait and severe muscular atrophy. Sensory abnormalities involved pin, light touch and vibration perception. In three years he had severe weight loss. Blood test revealed HBV infection and high levels of antibodies to transglutaminase, endomysium, and gliadin. EMG showed sensorimotor asymmetric axonal neuropathy. Nerve biopsy showed fiber loss, axonal degeneration with asymmetrical distribution and focal ischaemia. A duodenal biopsy was consistent with celiac disease. The patient was treated with high dose steroids, plasma exchange, immunoglobulin and lamivudine and began a gluten‐free diet. At discharge he could walk unassisted; sensory abnormalities were greatly reduced. One year later a new duodenal biopsy showed a complete resolution of the pathological abnormalities. Celiac disease, a chronic inflammatory intestinal disease whose pathogenesis involves a HLA DQ2‐DQ8 restricted T‐cell immune‐reaction, can be related to a higher risk of autoimmune disorders, such as insulin‐dependent diabetes or thyroid disease. We report the association of celiac disease, polyarteritis nodosa and HBV infection in a patient who developed a neuropathy and discuss the pathogenetic implications.

Paralysie du nerf abducens secondaire à une hypotension intracrânienne spontanée

Described by Schaltenbrand (1940), spontaneous intracranial hypotension is an unusual syndrome, sometimes revealed by an abducens nerve palsy motivating the patient to consult emergency ophthalmology services. The Authors report the case of a 50-Year-old Turkish woman who presented with diplopia due to a left abducens nerve palsy. These symptoms were associated with headache and nausea. Brain magnetic resonance imaging demonstrated diffuse pachymeningeal enhancement with gadolinium. A lumbar puncture showed low spinal fluid pressure (6 cm H2O), leading to the diagnosis of palsy by spontaneous intracranial hypotension. First, a classic treatment was prescribed with no result: increased water intake, corticoid therapy, and rest. Then a blood patch consisting of an injection of autologous blood by lumbar puncture between the third and fourth lumbar vertebrae to plug the spontaneous leak of spinal fluid, with success. A review of the literature provides information on the physiopathological mechanism, the clinical and imaging symptoms, and the treatment.

Papilledema and abducens nerve palsy following ethylene glycol ingestion

A 34-year-old male with a long-standing history of polysubstance abuse and depression was admitted for acute renal failure and hemodialysis secondary to ethylene glycol ingestion that occurred two days prior. The patient was admitted with documented ethylene glycol levels of 41.2 mg/dl, which fell to 25.0 mg/dl after 8 hours and to 6 mg/dl after 12 hours. One week later the patient presented to the outpatient eye clinic complaining of headaches and diplopia. On exam, vision in both eyes was 20/20. No afferent papillary defect was present. The patient had a left abducens palsy. The remainder of the anterior segment exam was normal. On dilated fundus exam the patient was found to have 3+ disc edema with hemorrhages in both eyes. A lumbar puncture revealed elevated intracranial pressure. In our opinion, the patient developed a left abducens nerve palsy and bilateral disc edema secondary to a transient rise in intracranial pressure after ingestion of ethylene glycol.

Vertebrobasilar artery dissection presenting with simultaneous subarachnoid hemorrhage and brain stem infarction: case report

Background Intracranial dissecting aneurysms have been associated with subarachnoid hemorrhage (SAH) or cerebral ischemia. We encountered a patient presenting with simultaneous subarachnoid hemorrhage and brainstem infarction caused by a dissecting aneurysm of the vertebrobasilar artery, which was diagnosed by magnetic resonance imaging (MRI) but did not show abnormal findings on cerebral angiography. Case description A 55-year-old man had sudden onset of headache and left abducens palsy. Computed tomography revealed a subarachnoid hemorrhage localized in the left prepontine cistern and the left cerebellomedullary fissure. Cerebral angiography showed neither a saccular aneurysm nor fusiform dilatation causing the subarachnoid hemorrhage. MRI demonstrated a small infarction in the left dorsal pons, and an intramural hematoma of the left vertebral artery and lower basilar artery. Conclusion This is a rare case of a vertebrobasilar dissecting aneurysm that simultaneously caused both SAH and brain stem infarction. MRI should be performed in the acute phase of SAH of unknown origin to determine the possible coexistence of a dissecting aneurysm, as occurred in this case.

Diplopia in a patient with carcinomatous meningitis: a case report and review of the literature

In a patient with a history of malignancy, an isolated neurologic sign or symptom may indicate metastasis to the central nervous system. To exclude this possibility, a lumbar puncture should still be performed after a nondiagnostic cranial computed tomography (CT) scan even in the absence of signs of infection. A case is presented of a 59 year-old man recently diagnosed with non-Hodgkin’s lymphoma that presented to the Emergency Department (ED) with the sole complaint of diplopia. Examination was unremarkable except for a left abducens nerve palsy. Cranial CT scan was normal but initial cerebrospinal fluid results were suggestive of carcinomatous meningitis, and cytology results later confirmed this diagnosis. A review of diplopia and carcinomatous meningitis is presented, along with a suggested conservative diagnostic algorithm for cancer patients presenting with neurologic signs or symptoms.