Left Sixth Nerve Palsy Research Articles

Bevacizumab‐induced transient sixth nerve palsy in ovarian cancer: A case report

We report a case of transient sixth nerve palsy after systemic administration of bevacizumab. Two days after systemic administration of bevacizumab in conjunction with gemcitabine and carboplatin in a 67-year-old woman with recurrent primary ovarian cancer, the patient developed sixth nerve palsy. After bevacizumab was stopped, the complete left sixth nerve palsy resolved spontaneously over the course of 3 months. This is the first reported case of bevacizumab-induced cranial sixth nerve palsy in the treatment of gynecologic malignancy.

When a bruise is not just a bruise

A 58-year-old woman developed binocular diplopia after violently retching during an episode of gastroenteritis. She experienced discomfort over the left lower eyelid and then developed diplopia, maximal on left gaze....

Dissecting Aneurysm of Vertebral Artery Manifestating as Contralateral Abducens Nerve Palsy

Isolated abducens nerve paresis related to ruptured vertebral artery (VA) aneurysm is rare. It usually occurs bilaterally or ipsilaterally to the pathologic lesions. We report the case of a contralateral sixth nerve palsy following ruptured dissecting VA aneurysm. A 38-year-old man was admitted for the evaluation of a 6-day history of headache. Abnormalities were not seen on initial computed tomography (CT). On admission, the patient was alert and no signs reflecting neurologic deficits were noted. Time of flight magnetic resonance angiography revealed a fusiform dilatation of the right VA involving origin of the posterior inferior cerebellar artery. The patient suddenly suffered from severe headache with diplopia the day before the scheduled cerebral angiography. Neurologic examination disclosed nuchal rigidity and isolated left abducens nerve palsy. Emergent CT scan showed high density in the basal and prepontine cistern compatible with ruptured aneurismal hemorrhage. Right vertebral angiography illustrated a right VA dissecting aneurysm with prominent displaced vertebrobasilar artery to inferiorly on left side. Double-stent placement was conducted for the treatment of ruptured dissecting VA aneurysm. No diffusion restriction signals were observed in follow-up magnetic resonance imaging of the brain stem. Eleven weeks later, full recovery of left sixth nerve palsy was documented photographically. In conclusion, isolated contralateral abducens nerve palsy associated with ruptured VA aneurysm may develop due to direct nerve compression by displaced verterobasilar artery triggered by primary thick clot in the prepontine cistern.

Progressive Diplopia and Facial Weakness in a 62-Year-Old Woman

Progressive Diplopia and Facial Weakness in a 62-Year-Old Woman

Transcortical Venous Approach for Direct Embolization of a Cavernous Sinus Dural Arteriovenous Fistula

Dural arteriovenous fistulas (dAVFs) represent 10% to 15% of all intracranial arteriovenous malformations. Most often, embolization is accomplished with transfemoral catheter techniques. We present a case in which embolization of a cavernous sinus dAVF was made possible through transcranial cannulation of a cortical draining vein. An 82-year-old woman presented with diplopia, left sixth cranial nerve palsy, intraocular hypertension, and bilateral chemosis. Angiography revealed a complex cavernous dAVF with cortical venous reflux, supplied by both external carotid arteries and the left meningohypophyseal trunk. Percutaneous transvenous access failed, and only partial occlusion was achieved by transarterial embolization. A frontotemporal craniotomy was performed to access the superficial middle cerebral vein in the left sylvian fissure. Under fluoroscopic guidance, a microcatheter was advanced through this vein to the floor of the middle cranial fossa and into the dAVF, permitting coil occlusion. This transcranial vein technique may be a useful adjunct in dAVF therapy when percutaneous transarterial or transvenous approaches fail or are not possible.

Abducens Nerve (VI) Injury Caused by Halo-Femoral Traction: A Case Report

Stretch and traction on cranial nerves during surgery may cause localized ischemia or change of position of the cranial nerve leading to subsequent dysfunction. Cranial nerve palsies (VI, IX, X and XII) are the commonly affected nerves. Here we report a cranial nerve VI palsy from a halo-femoral suspension following a posterior spinal fusion. We present an 11-year-old girl with idiopathic scoliosis who was admitted for surgical correction. She had no neurological problems preoperatively. The initial video-assisted thoracoscopic anterior release and cranial bifemoral traction were uneventful. Postoperatively, ten-pound weights were added at the head and another ten were added for counter-traction. Weights were added daily in 5-pound increments. Postoperative day 2, the patient complained of “double vision” which resolved upon decreasing the traction weight only by 5 pounds. She underwent an uneventful posterior spinal fusion one week later with a total intravenous anesthesia technique; motor evoked potentials were adequate throughout the procedure. One day later, she again developed left sixth cranial nerve palsy with inability to gaze laterally. There were no other neurological deficits, headaches or even double vision. Neurology and ophthalmology consultations excluded hypoxia/hypoperfusion as possible etiologies. The femoral pins and occipital frame were removed on day 3 in order to obtain imaging and also to remove a potential source of infection. The left lateral rectus palsy was noted to improve that same day. Radiological imaging results were ultimately normal. There is a need for frequent neurological examinations in patients in halo-tractions and prompt removal of the instrument at the first sign of eye problems. doi:10.4021/jnr39e

56-Year-Old Woman With Positional Headache

© 2011 Mayo Foundation for Medical Education and Research A 56-year-old woman presented to the emergency department with a 10-day history of sudden-onset, severe positional headache. She had awoken to sharp pain in the back of her neck extending into the occiput that subsequently radiated to the frontal areas bilaterally. She rated her pain as 10 on the 10-point severity scale. There was no history of recent head trauma. She had experienced associated nausea, vomiting, vertigo, increased pain when upright, and improvement when supine. Her medical history was remarkable for limited cutaneous scleroderma with CREST syndrome (named for its associated symptoms: calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia), type 2 diabetes mellitus, obstructive sleep apnea, hypercoagulable state with a positive lupus anticoagulant, hypertension with ischemic stroke, and multiple thromboses requiring long-term anticoagulation with warfarin. At presentation, all of her vital signs were within normal limits. Her physical examination was unremarkable, with the exception of hyperreflexia in the right upper extremity and bilateral lower extremities and left sixth cranial nerve palsy. Laboratory testing included a complete blood cell count, a metabolic panel, urinalysis, and measurement of troponin levels, which were all normal. The patient was noted to have a supratherapeutic prothrombin time with an international normalized ratio (INR) of 4.5 (target INR, 2.0-3.0).

Cerebral Sinovenous Thrombosis in a Child with Idiopathic Nephrotic Syndrome

Nephrotic syndrome (NS) is a renal disorder characterized by heavy proteinuria, hypoalbuninemia, edema and hypercholesterolemia. Nephrotic syndrome in children is known to be associated with an hypercoagulable state and thromboembolic complications. However cerebral sinovenous thrombosis (CSVT) is very rare. Here we report a seven-year-old child with steroid-dependent idopathic nephrotic syndrome resulting from a minimal change disease, developed multiple cerebral sinovenous thrombosis, presenting with headache, left sixth nerve palsy, and papilledema. The diagnosis of CSVT was established by cranial computed tomography, magnetic resonance imaging, and magnetic resonance angiography. He gradually recovered after anticoagulant therapy. CSVT is very rare in nephrotic children. The diagnosis of CSVT should be considered in any patient with nephrotic syndrome who develops neurologic symptoms. This report highlights the importance of suspecting and recognizing this potentially life threatening complication and initiating early treatment.

POC25 B-cell non-Hodgkin lymphoma presenting with diplopia, ataxia, and subacute polyneuropathy: neoplastic vs paraneoplastic?

A 74-year-old lady presented to a district hospital with ataxia, a left sixth nerve palsy, and a sensorimotor neuropathy over a several month period. Baseline blood tests revealed a macrocytic...

POI13 Acute respiratory failure in a multiple sclerosis relapse: successful treatment with plasma exchange

IntroductionRespiratory failure is an uncommon association with multiple sclerosis. We report on a patient with multiple sclerosis who developed bilateral diaphragmatic weakness and type II respiratory failure requiring mechanical ventilation,...

Abducens Ocular Neuromyotonia in a Patient With Nasopharyngeal Carcinoma Following Concurrent Chemoradiotherapy

We describe a case of ocular neuromyotonia (ONM) following concurrent chemoradiotherapy for nasopharyngeal carcinoma (NPC). During an episode of neuromyotonia, the patient developed involuntary contraction of the left lateral rectus muscle and globe retraction with down-shoot movement in the left eye. In the quiescent period, ocular motor examination revealed a partial left sixth nerve palsy. While diplopic complaints in patients with NPC raise suspicion of tumor recurrence or radiation-related cranial neuropathy, ONM must also be kept in the differential diagnosis.

Atlantooccipital dislocation in motor vehicle side impact, derivation of the mechanism of injury, and implications for early diagnosis

Numerous reports of atlantooccipital dislocations (AODs) have been described in frontal impacts and vehicle versus pedestrian collisions. Reports of survival after AOD in conjunction with side impacts have infrequently been reported in the literature. The objective of this study is to present a case of an AOD from a side impact vehicle collision, and deduce the mechanism of injury. A clinical and biomechanical reconstruction of the collision was performed to investigate the mechanism of the dislocation. A 51-year-old female was traveling in a four-door sedan and sustained a side impact collision with a compact pickup truck. At the time of extrication, the patient was neurologically intact with a Glasgow Coma Scale score of 15. After admittance to the hospital, the patient developed a decline in respiratory status, right mild hemiparesis, and left sixth-nerve palsy, and magnetic resonance imaging (MRI) and computed tomography (CT) reconstructions indicated a craniocervical dislocation. Surgical fixation was performed and all extra-axial hemorrhaging was evacuated. At discharge, the patient was neurologically intact on the left side, had right mild hemiparesis, left sixth-nerve palsy, and minor dysarthria. Survival rates of AODs have recently been increasing. Morbidity is still more prevalent, however. Due to the variety of symptoms that accompany AODs and the inconsistency of diagnostic imaging techniques, a thorough history of the etiology may lead to increased clinical suspicion of this injury and further raise survival rates.

“Ophthalmoplegic Migraine” With Reversible MRI Enhancement of the Cisternal Sixth Cranial Nerve

A 45-year-old woman reported multiple episodes of reversible left eye pain and diplopia stretching over 12 years. Ophthalmic examinations had repeatedly disclosed a left sixth cranial nerve palsy. Postcontrast brain MRI performed 3 weeks after clinical onset of the most recent episode demonstrated enhancement of the cisternal segment of the left sixth cranial nerve. Five months later, when symptoms and signs had largely abated, postcontrast brain MRI was normal. The clinical diagnosis satisfies the criteria for "ophthalmoplegic migraine." Although reversible cisternal enhancement of the third cranial nerve has been often described in this condition, this is the first report of cisternal enhancement of the sixth cranial nerve.

Fatal Septic Thrombosis of the Superior Sagittal Sinus After Face-lift Surgery Caused by Community-Associated Methicillin-Resistant Staphylococcus aureus

Fatal Septic Thrombosis of the Superior Sagittal Sinus After Face-lift Surgery Caused by Community-Associated Methicillin-Resistant <i>Staphylococcus aureus</i>

Primary Pituitary Lymphoma: A Histological, Immunohistochemical, and Ultrastructural Study with Literature Review

We report the case of a 62-year-old man with headache and left sixth cranial nerve palsy. A computerized tomography scan revealed an osteolytic process involving the sella turcica and clivus. A partial tumor resection was achieved via an endoscopic transsphenoidal approach. Morphologic investigation revealed a diffuse large B cell lymphoma involving pituitary parenchyma. No systemic disease was found upon staging. Primary pituitary lymphoma is extremely rare. An accurate histologic diagnosis is key to successful treatment and a favorable prognosis. The literature is reviewed.

Resolution of anterior segment ischemia after the removal of lateral fixation sutures

Anterior segment ischemia is a rare but well-recognized complication after strabismus surgery, involving multiple extraocular muscles. We report a case of traumatic left sixth nerve palsy in a 32-year-old man who developed anterior segment ischemia after left medial rectus muscle recession and partial tendon transfer of the vertical rectus muscles to the lateral rectus, augmented by lateral fixation sutures. The corneal edema and anterior chamber reaction cleared upon removal of the lateral fixation sutures and institution of steroids and cycloplegics. The possible role of lateral fixation sutures in anterior segment ischemia is discussed.

Clivus Chordoma: An interesting clinical presentation

Clivus chordomas are rare central nervous system tumors which arise from base of the skull. We present a 10 year old female who presented with unique bulbar symptoms and and vascular compressive symptoms. We emphasize the fact that these tumors are rare in children with less than 25 cases reported in children, and pose a diagnostic and therapeutic challenge CASE A 10-year-old female presented with three-month history of moderate frontal headaches. Three days prior to her admission she developed double vision and drooping of her right eyelid. Past medical, family, birth history was insignificant. Comprehensive physical examination was normal except, presence of right third nerve palsy and left sixth nerve palsy with binocular diplopia. Anisocoria with right pupil 5mm and left 3mm both reacting to light, was present. MRI of the brain revealed mass arising from clival skull base. The tumor was very large 4.5x2.7x2.6 cm compressing the brain stem Figure (FIG 1-C) with deviation of right internal carotid and basilar artery flow voids. Day 4 she developed acute onset left sided weakness. MRI of the brain revealed right MCA infarct and patient was taken for two-staged subtotal chordoma resection. CT Angio revealed right occlusion of the cavernous part of the right internal carotid artery. Pathology confirmed clivus chordoma. Figure 1 Figure 1a: Saggital T-1 weighted MRI imaging depicting compression of the brainstem by a hetergenous mass arising from the clival plate Clivus Chordoma: An interesting clinical presentation 2 of 3 Figure 2 Figure 1b: Axial MRI Diffusion Weighted imaging shows Right middle cerebral artery infarct. This finding was confirmed with corresponding hypo intensity on ADC mapping consistent with an ischemic infarct Figure 3 Figure 1c: Saggital CT Angiogram of the neck and brain shows right carotid occlusion. DISCUSSION Clival chorodomas are extremely rare skull based tumors arising from notochordal remnants, which have difficult surgical access, high local recurrence rate and metastatic potential. As per review by Yadav et al (1), less than 25 cases have been reported in young children. Our patient had compressive right carotid occluson with clivus chorodoma, which was partially resected. Postoperatively, patient has left sided hemplegia with resolved cranial nerve deficits. We emphasize importance this unique clinical presentation with vascular and bulbar compressive symptoms. CORRESPONDENCE TO Archit Bhatt MD, MPH 138 service road East Lansing,MI 48823 646-369-5208

Isolated Sixth Cranial Nerve Palsy in Preeclampsia

Isolated Sixth Cranial Nerve Palsy in Preeclampsia

Adult‐Onset Ophthalmoplegic Migraine with Recurrent Sixth Nerve Palsy: A Case Report

We describe a patient with ophthalmoplegic migraine and left sixth nerve palsy, in whom disease's onset occurred at middle age.

Isolated sixth nerve palsy secondary to spontaneous intracranial hypotension

We report the case of a 43-year-old gentleman who presented with an isolated left sixth nerve palsy in association with postural headache. Magnetic resonance imaging showed dural enhancement with downward displacement of the brainstem. This, in association with the signs, symptoms and findings on lumbar puncture, confirmed the diagnosis of spontaneous intracranial hypotension. Treatment was successful with epidural blood patching. The case is discussed and the relevant literature reviewed.