Left Sixth Nerve Palsy Research Articles

Idiopathic Intracranial Hypertension With Unusual Presentation in an Adolescent Girl: A Case Report

Background: Idiopathic intracranial hypertension (IIH) or pseudotumor cerebri is a rare disorder. Regarding the latest diagnostic criteria for this disorder, we present a rare case of IIH. Case presentation: The case was an 11-year-old girl referred to our center with generalized body pain and mild left-eye deviation with no other visual symptoms. She had a severe generalized pain especially in her back and prevertebral area. In the neurological examination, there was a mild left sixth nerve palsy and bilateral papilledema. We treated the patient with acetazolamide and to lumbar puncture, which reduced intracranial pressure. The generalized body pain was reduced gradually in ten days, eye deviation in three weeks, and papilledema in two months after treatment. Conclusion: Based on the serious complications of IIH, a thorough assessment of suspicious cases, including ophthalmoscopic examinations, is mandatory. Furthermore, clinicians should consider even rare and unknown specific symptoms in these patients.

Left Sixth Nerve Palsy and Subdural Hygroma Following Intrathecal Morphine Pump Placement: A Case Report

BACKGROUND: An intrathecal (IT) pump is an effective drug delivery system that assists patients with chronic pain management. However, due to the invasive nature of the procedure, a complication that could arise is cerebrospinal overdrainage or leak, which could lead to adverse effects. CASE REPORT: The patient underwent an IT morphine pump implant for treatment of his chronic, intractable low back pain. Following the procedure, he developed persistent headaches and diplopia and was found to have left lateral rectus palsy. Imaging studies showed the development of bilateral subdural hygromas. His condition was resolved with surgical intervention and time. CONCLUSIONS: After an extensive literature search and review, to our knowledge, this is the first reported case of sixth nerve palsy and subdural hygromas following the implant of a drug delivery system. KEY WORDS: Abducens palsy, IT pump, subdural hydrgomas, intrathecal drug delivery system, lateral rectus palsy

NIMG-77. EARLY DIAGNOSIS OF NEUROCUTANEOUS MELANOSIS MASQUERADING AS SUBARACHNOID HEMORRHAGE

Abstract A 50-year-old male presented to the emergency room with a sudden onset right upper limb facial numbness and dysphasia, soon followed by full-recovery. Brain computed tomography revealed hyperdense lesions within the left frontal sulcus, highly suspicious of subarachnoid hemorrhage. T1-weighted magnetic resonance imaging showed multiple leptomeningeal enhancement in the left frontal area.The digital subtraction angiography indicated an absence of vascular lesions. One-month after, the lesions progressed in the occipital area, when left sixth nerve palsy developed. Multiple giant nevus over the legs, trunk, and scalp had attracted attention. Owing to the suspicious symptomatic leptomeningeal lesions, open biopsy was performed. Surprisingly, diffuse, thick, black-colored tissue infiltration of the subarachnoid space, involving prominent cortical vessels, was noted. Pathology confirmed meningeal melanocytosis. Neurocutaneous melanosis is characterized by giant congenital or multiple satellite nevi and melanocytic tumors of the leptomeninges. Early disease diagnosis is crucial. Once the patient develops neurological symptoms, prognosis could quickly worsen.

Multiple Sclerosis Presenting as Intracranial Hypertension in the Setting of COVID-19 Infection

Background: Multiple sclerosis (MS) and idiopathic intracranial hypertension (IIH) occur more commonly in women of childbearing age. There are altered cerebrospinal fluid dynamics in both diseases, causing them to have similar presentations at times. Coronavirus disease 19 (COVID-19) has also been reported to affect the central nervous system (CNS) of any age. Case Presentation: We report a19 year old male who initially presented with headaches and fever, and was diagnosed with COVID-19 infection. A few days later, he developed acute severe left eye pain, blurred vision, diplopia, and left ear tinnitus. The patient was found to have reduced visual acuity, left sixth nerve palsy, esotropia and asymmetric bilateral papilledema. Later, he developed left facial nerve palsy. MRI of the brain showed extensive demyelinating lesions. Lumbar puncture revealed significantly increased intracranial pressure (ICP) and positive oligoclonal bands. Conclusion: This is a unique case of MS presenting with intracranial hypertension (IH) in the setting of COVID-19 infection that could have been the trigger for the MS clinical attack.

Double under muscle transposition in long-standing sixth nerve palsy: A case report

Introduction: To report a case of acquired esotropia after long-standing sixth nerve palsy with double under muscle transposition technique correction. Case Report: A 41-year-old male presented with diplopia from an unruptured and thrombosed mid-basilar aneurysm that caused isolated left sixth nerve palsy for 18 months after undergoing surgery. He had left face turn, 66 prism diopters (PD) esotropia of the left eye, and a complete left abduction deficit. To improve a complete sixth nerve palsy, we performed a double-under muscle transposition (DUT) technique, vertical recti [superior and inferior (SR) and (IR)] were transposed under left lateral recuts (LR) muscle along with medical recuts (MR) recession. Following postoperative result at three months, he was found to be orthotropia at near and 8 PD of exotropia at distance. He also improved diplopia in the primary position and he could slightly abduct the left eye. He did not have any postoperative complication. Conclusion: We demonstrated that a DUT technique can be a procedure of choice in patients with large angle deviation from paralytic strabismus.

New-Onset Headache and Abnormal Eye Movements in a Four-Year-Old Child: Indicators of Increased Intracranial Pressure

A four-year-old previously healthy child presented with new-onset, diffuse, severe headache, and left sixth nerve palsy. The child was evaluated at several acute care facilities, at which the symptom of "crossing eyes" was not addressed specifically. At our emergency department, on day 6 of symptoms, a left cranial nerve 6 palsy was diagnosed; on brain MRI scan, there was evidence of increased intracranial pressure (distended optic nerve sheaths, flattened posterior sclerae), which was confirmed by lumbar puncture, which showed an opening pressure of >36 cm H2O. Idiopathic intracranial hypertension (IIH) was diagnosed, and all symptoms abated with two months of treatment with acetazolamide. IIH should be considered in a child with headache and abnormal eye movements.

Clival Chondroma with Brainstem Invasion Findings in MRI: A Case Report

Chordoma is a rare neoplasm derived from remnants of the fetal notochord; the most commun locations are the lumbosacral spineand the clivus. Clival chordomas represent 35 to 40% of cases and are very difficult to treat because of the localization and high recurrence rate. We present the case of 60 years old male patient with no previous history consulting for diplopia and headach that worsened in the last week before the diagnosis, with a walking ability disorder. Neurological examination found a raised intracranial pressure syndrome with static cerebellar syndrome. However, he presented left hemifacial numbness due to left fifth cranial nerve palsy and diplopia at left gaze due to left sixth cranial nerve palsy. The diagnosis was made by MRI using the different sequences especially T1 SE, T1 GE, T2 FLAIR, DWI and spectroscopy.

Recurrent Ophthalmoplegia Associated with Hyperhomocysteinemia

Purpose: This report describes a case of recurrent ophthalmoplegia associated with hyperhomocysteinemia due to methylenetetrahydrofolate reductase (MTHFR) gene polymorphism.Case summary: A 40‐year‐old healthy man presented with acute diplopia. He had a history of diplopia due to left sixth nerve palsy 2 years ago. Prism and alternate cover tests revealed left hypertropia in the primary position. Examination of ductions and versions showed mild elevation of the left eye on adduction. Brain and orbit magnetic resonance imaging were normal. Laboratory studies revealed an elevated level of erythrocyte sedimentation rate (ESR) and homocysteine. A diagnosis of left fourth nerve palsy associated with hyperhomocysteinemia was made. Symptoms were completely resolved within 2 weeks. Two years later, the patient again had diplopia associated with esotropia and limited abduction of the right eye. ESR and homocysteine level were normal. Analysis for MTHFR gene polymorphisms, which contribute to variable hyperhomocysteinemia, revealed 677TT homozygote variant. A diagnosis of recurrent paralytic strabismus associated with hyperhomocysteinemia, caused by MTHFR gene polymorphism, was made. Symptoms resolved within 1 month, and the patient did not have any further recurrence in 6 months.Conclusions: Patients with hyperhomocysteinemia may present with ophthalmoplegia. An analysis for MTHFR gene polymorphisms is needed to diagnose hyperhomocysteinemia.

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.

‘Look into Their Hearts’ 7-Year-Old Boy with Sickle Cell Disease, Fever, Left Sixth and Seventh Cranial Nerve Palsy and Left Hemiplegia

A 7-year-old Liberian boy presented with fever, severe headache, neck pain and 'not being able to walk'. In the emergency room, his sickle cell screen was positive, and his haemoglobin level was 7g/dl. Initially, he was admitted to the ward with a diagnosis of sickle cell painful crisis and was treated with ceftrixone iv, and oral morphine and paracetamol. In a more complete physical examination, he had left peripheral seventh nerve palsy, left sixth nerve palsy and ipsilateral hemiplegia, also neck rigidity. In a bedside ultrasound scan, he had a large, mobile vegetation on the aortic leaflet of the mitral valve. The final diagnosis was acute infective endocarditis with multiple embolic strokes in a child with sickle cell disease. Headache and neck rigidity was most likely due to SAH or meningitis.

Abducens Nerve Palsy as the First Manifestation of Type Two Diabetes Mellitus

Abstract Introduction: Diabetes mellitus has varied presentations at different times from onset. One of the uncommon presentations is cranial nerve palsy secondary to microvascular ischemia. Approximately 20% of isolated abducens nerve palsies are secondary to vascular microangiopathy. Clinical Case: A 53-year-old female with no significant past medical history presented to the emergency department with concerns of double vision. The patient first noticed her symptoms five days prior to presentation. The patient endorsed blurry vision and stated that she has double vision in certain gazes that resolves with shutting either eye. Furthermore, she has also developed headaches during that period, described as a pressure-like sensation in her forehead and behind her eyes. She otherwise denied any tearing, redness, or pain. On review of systems, she denied numbness, tingling, changes in hearing, changes in speech, or extremity weakness. Due to the persistence of symptoms the patient presented to the emergency department. On exam, the patient’s vitals were normal. Pupils were equal and briskly reactive to light with no relative afferent pupillary defect. External examination was unremarkable without scalp tenderness, proptosis, or ptosis. Color vision was intact. Ocular motility testing revealed limited abduction of the left eye causing double vision on lateral gaze. Confrontation visual fields were full in each eye. Bilateral lower extremity exam revealed decreased sensation in the sole of the foot. The rest of the physical exam was unremarkable. Laboratory work revealed blood glucose level of 305 mg/dl (Reference range 70–99 mg/dl). HBA1C was 12.3% (Reference range 3.8–5.6%). CT head and CTA of the neck was performed and were unremarkable. Given the normal imaging and findings on examinations, her ocular motor findings were attributed to diabetes mellitus. The patient was started on insulin, aspirin, and received diabetic education for lifestyle modification, and was scheduled for outpatient follow up. The patient’s acute isolated left sixth cranial nerve palsy was most likely owing to microvascular ischemia from previously undiagnosed diabetes mellitus. A study of 59 patients with an isolated sixth cranial nerve palsy showed a 6-fold increase in the odds of having diabetes compared with controls.(1) Conclusion: Given the infrequent presentation of Diabetes with Abducens nerve palsy, diagnosis is usually delayed with the expense of ordering costly investigations that put a financial and psychological burden on patients. Thus, we urge clinicians’ awareness when encountering cases of isolated cranial nerve palsies.

Oculomotor nerve palsy related to COVID-19. A case report

Objective: To report a case of a patient infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) associated with oculomotor paresis of the sixth cranial nerve Case report: A 49-year-old patient reported a 2-month history of horizontal diplopia In addition to diplopia, the patient had mild respiratory symptoms with positivity to SARS-CoV-2 Ocular examination revealed an esotropia of 20 prism diopters, as well as a limitation of the abduction of the left eye of -1 5 The patient was diagnosed with left sixth nerve palsy that required treatment with botulinum toxin type A

Case Report: The Dilemma of Imaging an Isolated Sixth Nerve Palsy

Background: Traditionally, eyecare providers employ a wait-and-see approach with respect to older patients presenting with a presumed vasculopathic isolated sixth nerve palsy. However, given review of recent literature and the potential of morbidity in these patients, acute neuroimaging should be strongly considered. Eyecare providers are often faced with challenging decisions when patients present with acute isolated oculomotor nerve palsies. This case highlights the diagnostic dilemma of an older patient with significant vasculopathic risk factors who presents with an isolated sixth nerve palsy. For patients older than 50, a vasculopathic etiology is the most likely cause, however, a small but significant percentage of these patients may suffer from a more ominous condition such as, giant cell arteritis, intracranial mass, or aneurysm. As evidenced by our case, acute neuro imaging should be considered in all isolated sixth nerve palsies. Case Report: A 69- year old Caucasian male presented to the VA Connecticut Healthcare System with new onset diplopia. The patient reported a recent history of mild orbital pain and headaches. Evaluation revealed an isolated left sixth nerve palsy. A microvascular etiology was presumed given his strong vasculopathic history. One week later the patient returned to clinic with a new left pupil-sparing third nerve palsy in addition to his original left sixth nerve palsy. Magnetic resonance imaging of the brain and orbits with and without contrast revealed a left cavernous sinus mass. The patient was transferred to the Smilow Cancer Hospital at Yale-New Haven and received gamma knife radiosurgery for the presumed neoplastic lesion. Conclusion: Although support can be made for both a “wait-and-see” approach and acute diagnostic imaging, our case highlights the benefits of early imaging. Appropriate acute neuro imaging in patients with presenting isolated sixth nerve palsies can be lifesaving.

Bilateral Giant Opthalmic Carotid Artery Aneurysms Presenting as Unilateral Diplopia: A Case Report

Introduction: The etiology of giant aneurysms is multifactorial. It becomes symptomatic in 9/100.000, most frequently in the fifth and sixth decades of the life. Intracavernous carotid artery aneurysms (ICAAs) represent less than 1% of intracranial aneurysms and show a slight female predominance. Case-Report: We report an interesting case of bilateral ICAA in 42-year-old female presented as acute diplopia and emphasize the need of a thorough systemic evaluation in young patients with diplopia and treated with endovascular coil embolization. A 42-year-old woman was admitted to the neurology department suffering from the unilateral diplopia. Neurological examination showed the left sixth cranial nerve palsy and had no further general motor or sensory symptoms. Digital Subtraction Angiogram (DSA) showed bilateral ophthalmic artery aneurysm. The patient was treated with endovascular loose packing coil embolization and Derivo 3.5x30mm flow diverter stent. Conclusion: It should be kept in mind that intracavernous carotid artery aneurysms may be bilateral in patients with unilateral cranial nerve symptoms.

Multifocal Stroke From Ozone Gas Emboli

A 34-year-old man with chronic neck pain was treated with regular cervical paravertebral ozone injections. After his last injection, he experienced a syncopal episode and, upon awakening, was found to have ataxia, aphasia, hemiparesis, and left sixth nerve palsy. Computed tomographic angiography demonstrated intra-arterial gas in the right vertebral artery; multiple posterior circulation infarcts were seen on brain MRI. This case illustrates the potential dangers of paravertebral injections of ozone.

Chronic Sixth Nerve Palsy due to Compression by the Anterior Inferior Cerebellar Artery.

A 65-year-old healthy woman presented with a 15-year history of binocular horizontal diplopia worse when looking left. She had previously been thoroughly investigated multiple times for a left sixth nerve palsy (6NP) 15 years ago and had three normal magnetic resonance imaging (MRI) scans of the brain/orbits with contrast, normal acetylcholine receptor antibodies, normal thyroid function tests, normal cerebrospinal fluid, and normal nerve conduction studies and single-fibre electromyography. She was treated with prism glasses, which resulted in resolution of her symptoms in primary position.

Primary Central Nervous System Lymphoma Presenting with Peripheral Neuropathy; A Rare Case of Coincident PCNSL and Mononeuritis Multiplex

A 43-year-old male presented with diplopia and right sixth-nerve palsy. Brain magnetic resonance imaging (MRI) demonstrated a lesion in the right periventricular area. High-dose corticosteroid pulse therapy did not resolve the symptom. After one month, his diplopia progressed and he developed weakness of the left lower limb. Detailed examination revealed left sixth-nerve palsy, dropped foot, waddling gait, atrophy of the gluteal muscles and mild atrophy and weakness of the right upper limb. Neurological examination supported evidence of multiple cranial nerve palsies along with asymmetrical peripheral neuropathy. Electrodiagnostic studies were compatible with a mononeuritis multiplex. Rheumatologic evaluations were normal. Malignancy work-up were normal, except for some insignificant lymph nodes. Bone marrow aspiration and biopsy were normal. The second brain MRI detected multiple homogenous enhancing lesions in the right periventricular area.The result of stereotactic biopsy and immunohistochemistry staining demonstrated primary B-cell CNS lymphoma (PCNSL). Mononeuritis multiplex has not been reported as a paraneoplastic manifestation of PCNSL yet. In other words, it is not clear whether involvement of the peripheral nervous system in our patient is a paraneoplastic manifestation of PCNSL or a coincidence of PCNSL and hematologic lymphoma presenting with peripheral vasculitic neuropathy. It is recommendedthat future studies focus more on symptoms associated with PCNSL to recognize the exact relationship between PCNSL and peripheral neuropathy.

Pure Intrinsic brain stem epidermoid cyst: Case report, review of the literature and new classification

Epidermoid cysts are one of the uncommon slow growing lesions. There is some amount of controversy prevailing in the uniform understanding of these among the researchers regarding the nomenclature of these lesions. With a critical review of reported cases, author demarcated four different anatomical types of brain stem epidermoids and proposed a new classification system for a better understanding of the natural history.Four years female child presented with insidious onset left sixth and seventh cranial nerve palsy with right hemiparesis. Radiological evaluation revealed a pure intrinsic brain stem cystic lesion. Surgical decompression of the cyst was done, and the child recovered well. Histopathological examination was an epidermoid cyst.Brain stem epidermoids are uncommon, and there is no age or sex predilection. Based on the epicenter these tumors could be classified into four different types. Adequate surgical excision is the hallmark in the treatment. Nepal Journal of Neuroscience, Volume 14, Number 3, 2017, page: 33-41

Multiple myeloma masquerading as abducens palsy: A case report.

Purpose: To report a case of abducens palsy as the presenting symptom of multiple myeloma Case report: A 68-year-old woman with a history of systemic hypertension presented complaining of constant horizontal diplopia in left gaze for six weeks. Her entering acuities were 20/25 in the right eye and 20/20 in the left eye. Extraocular muscle testing revealed left sixth nerve palsy without any misalignment in primary gaze. The remainder of her ophthalmic examination, including other neurological testing such as cranial nerve testing, pupils, and confrontation fields, was unremarkable. MRI of the brain and orbits indicated numerous osseous lesions throughout the skull with a high-risk lesion invading the left cavernous sinus and encasing both the left internal carotid artery and the left optic nerve. After receiving these results, she was referred urgently for further imaging, which revealed additional lesions throughout her axial and appendicular skeleton, including other high risk lesions in the thoracic spine and the pelvis. Further workup confirmed the diagnosis of multiple myeloma. Conclusions: Ophthalmic findings related to multiple myeloma are generally rare and tend to occur late in the course of known disease. In this case, ipsilateral isolated sixth nerve palsy was the presenting sign of multiple myeloma in a patient. Although neurological etiology is not common with sixth nerve palsies, neurological workup including imaging should be considered routinely in patients who present with isolated sixth nerve palsy, particularly when vasculopathic risk factors are not suggested by patient history.

P10.02 * UTERINE CARCINOSARCOMA WITH PARANEOPLASTIC CEREBELLAR DEGENERATION: CASE ANALYSIS WITH LITERATURE REVIEW

INTRODUCTION: Paraneoplastic neurologic syndromes (PNS), a heterogeneous group of oncologic immune-mediated neurologic disorders, often antedate cancer diagnosis. PNS recognition results in early cancer screening/treatment. Paraneoplastic cerebellar degeneration (PCD) is an aggressive/debilitating/fatal PNS characterized by pancerebellar symptoms – progressive ataxia/dysarthria/nystagmus/vertigo. PCD is predominantly associated with breast/gynecologic cancers. Though 12 onconeural antibodies are implicated in PCD, anti-Yo antibody is the most common/specific antibody seen in PCD. We present the first case of anti-Yo PCD associated with uterine carcinosarcoma. METHOD: Case analysis. CASE: 78yo female presented with month-long history of ataxia/gait instability/falls and abrupt onset diplopia/nausea/vomiting without fever/syncope/headache /dysarthria. Past medical history was significant for right breast T1 N0 invasive ductal carcinoma s/p partial mastectomy and adjuvant whole breast radiation that occurred 1 year prior to presentation. Neurologic exam revealed intact language/comprehension, left sixth cranial nerve palsy, truncal/limb ataxia, bilateral horizontal nystagmus, and symmetric 3+ deep tendon reflexes without focal deficits or dystonia noted. Routine blood work was unremarkable. Brain MRI with/without contrast noted no evidence of metastatic disease/demyelinating process/hemorrhage/infarction. She declined CSF studies. Within two months, she developed dysarthria/dysphagia and was unable to stand without assistance due to progressive ataxia. PNS laboratory evaluation yielded high titer of anti-Yo antibody (1/245,760) with positive Western blot assay as the only onconeural antibody. Chest/abdomen/pelvis CT scan demonstrated multiple soft tissue lesions in the omentum with bilateral sub-centimeter pulmonary nodules. Tumor marker analysis noted elevated CA-125/CA-27.29/CA-15.3. CT guided biopsy of omental lesions revealed poorly differentiated carcinosarcoma. Immunohistochemistry confirmed malignant stage IV uterine carcinosarcoma. Chemotherapy with IVIG was initiated. Though tumor burden size decreased, PCD progressed (bedbound, increased anti-Yo antibody titers). Rapid neurologic decline required hospice 8 months after PCD diagnosis associated with uterine carcinosarcoma. She died 1 month later. CONCLUSIONS: This case confirms anti-Yo PCD association with uterine carcinosarcoma. PCD requires early cancer screening/treatment and aggressive multi-modal immunotherapy interventions. Clinicians should have a low threshold for PCD. Double primary cancers must be considered. Prospective trials addressing anti-Yo PCD therapeutic interventions, illness progression, associated cancer, double primary, and survival are indicated. Clinicians require further education regarding PCD and other PNS.