The objection of the study was to evaluate the features of pediatric idiopathic intracranial hypertension (IIH) at different age groups. This prospective study was done in Pediatric Neurology Department, National Institute of Neurosciences and Hospital, Bangladesh from January 2018 to June 2020. Total 19 cases were enrolled who were clinically suspected and had normal CSF with opening pressure (OP) above 250 mm H2O. They were further categorized as Group I (early- onset pediatric IIH) and Group II (late-onset pediatric IIH) according their age of onset. All patients underwent thorough neurological and ophthalmological evaluations. Clinical and laboratory findings were analyzed by SPSS version 22.0. Mean age was 8.1±2.07 years in Group I and 11.77±0.44 years in Group II. Male were found predominant in Group I while female was more in Group II (p=0.255). Headache (100.0%), vision (70.0%), vomiting (60.0%) irritability (30.0%) and papilledema (90.0%) and sixth nerve palsy (80.0%) were common clinical presentation among Group I. Diffuse headache was more in Group II. Obesity was found significantly more in Group II than Group I (p=0.033). CSF analysis revealed normal cellular and biochemical profiles in all patients. Mean CSF opening pressure was higher in Group I (23.0±9.83 cmH2O) compared with Group II (20.66±4.33 cmH2O), although the difference was not statistically significant. A negative correlation was observed between age and CSF opening pressure. Brain MRI was normal in all cases. Routine laboratory investigations, including complete blood count, liver function tests, serum electrolytes and thyroid function tests, were unremarkable. There was a clear distinction between presentations of early onset and late onset pediatric IIH. Early onset IIH may present with higher CSF opening pressure and less association with obesity, whereas late-onset IIH shows a pattern more similar to adult IIH with increased obesity prevalence.

PurposeTo evaluate the clinical outcomes and safety of the Nishida muscle transposition procedure performed without tenotomy or muscle splitting in patients with severe paralytic horizontal or vertical strabismus.MethodsThis retrospective case series included 16 patients with complete paralytic strabismus who underwent Nishida transposition between January 2020 and September 2021. Eleven patients had abducens nerve palsy and five had vertical paralytic strabismus (elevation or infraduction deficiency). The procedure involved scleral fixation of adjacent rectus muscles closer to the paralyzed muscle without tendon disinsertion, preserving anterior ciliary circulation and allowing simultaneous antagonist recession when indicated. Outcomes included ocular alignment in primary position, ocular motility, binocular single vision, and postoperative complications over a follow-up period of 5-15 months.ResultsIn abducens nerve palsy, combined transposition with medial rectus recession-performed using a standardized protocol based on preoperative deviation (6 mm for ≥80 prism diopters [PD] and 5 mm for <80 PD)-achieved a mean correction of 69.2 ± 12.8 PD, whereas isolated transposition resulted in a correction of 29 PD. In vertical paralytic strabismus, the mean correction was 38 ± 19.8 PD. All patients demonstrated improved duction beyond the midline postoperatively. Eight patients achieved binocular single vision in primary position and four with compensatory head posture. No anterior segment ischemia, induced secondary deviations, or other major complications were observed.ConclusionsThe Nishida procedure provides effective and safe correction of severe paralytic strabismus while preserving muscle insertions and anterior ciliary circulation. Its compatibility with simultaneous antagonist recession makes it a valuable single-stage approach for large-angle paralytic deviations.

Idiopathic intracranial hypertension (IIH) is characterised by raised intracranial pressure in the absence of structural pathology and with normal cerebrospinal fluid composition. IIH is strongly associated with obesity and rising incidence has been reported in northern hemisphere countries. However, paediatric and Southern Hemisphere populations, including Australia, are under-represented in the existing literature. We conducted a multicentre retrospective study of adults (≥ 18years) and children (< 18years) diagnosed with definite IIH (Revised Friedman criteria 2013) between 2010 and 2023 at two Melbourne-based quaternary hospitals, capturing the majority of cases in Victoria, Australia. Demographic and clinical data were collected at diagnosis. Annual crude and age-standardised incidence rates per 100,000 population were calculated overall and by age group across predefined periods (2010-2014, 2015-2019, and 2020-2023). Temporal trends were assessed using negative-binomial regression. A total of 612 incident IIH cases were identified, including 504 adults and 108 children. Adults were predominantly female (94%), with mean age 28.0 ± 6.5years and mean BMI 37.6 ± 8.4kg/m2. Children showed lower female predominance (76%), younger mean age (12.4 ± 3.5years), and lower mean BMI (31.9 ± 8.4kg/m2). Headache was the most common presenting symptom in both groups (adults 84% and children 86%). Diplopia and sixth nerve palsy were more frequent in children. Age-standardised IIH incidence increased from 0.86/100,000 person-years in 2010-2014 to 6.53/100,000 in 2020-2023. In adults, incidence rose from 0.07/100,000 in 2010 to 2.30/100,000 in 2023 (32-fold); in children, from 0.33/100,000 to 1.01/100,000 (threefold). The highest incidence rates were seen among females aged 18-39years, in whom incidence rose from 0.11/100,000 to 6.79/100,000 between 2010 and 2023. IIH incidence in Victoria increased substantially over 14years, with the greatest burden among young adult females, mirroring international trends and highlighting the need for ongoing surveillance and mechanistic research.

Idiopathic intracranial hypertension without papilledema (IIHWOP) remains poorly understood. This review summarizes the diagnostic challenges and potential management of adults with IIHWOP. A detailed search of the scientific literature, combining MeSH and free-text terms, included all English-language papers on PubMed, from inception to June 8, 2025. In this review, we used the term IIHWOP to describe patients without evidence of active or previous papilledema. The diagnosis of IIHWOP is based on elevated lumbar puncture opening pressure accompanied by either sixth cranial nerve palsy or neuroimaging features of intracranial hypertension, which may lack specificity. Clinical presentation frequently mimics primary headache disorders, and lumbar puncture remains an invasive procedure without clear management implications in IIHWOP, as there are no high-quality studies evaluating medical or surgical therapies. Recommendations for investigation and clinical care remain largely inferred from idiopathic intracranial hypertension. Given the absence of evidence for risk of vision loss, invasive procedures should be avoided, and management should focus on weight loss and optimized headache management.

Papilledema is swelling of the optic disc due to increased intracranial pressure (ICP) which can cause neurological symptoms such as headache, nausea, vomiting, and progressive visual impairment and can lead to permanent blindness if not treated appropriately. This condition must be differentiated from disc edema due to other etiologies because it has a different pathophysiology and management. This case report discusses a 32-year-old woman who presented with complaints of blurred vision such as shadows in the left eye for five days, accompanied by frontal headache radiating to the retrobulbar, nausea, intermittent fever, and impaired eye movement. Ophthalmological examination showed decreased vision, limited mediolateral movement of both eyes indicating paresis of the sixth nerve, and fundoscopic images of bilateral blurred papilla borders with more severe swelling in the left eye accompanied by hard exudate. The patient was diagnosed with papilledema with diplopia ODS ec. paresis of the sixth nerve and was given supportive therapy in the form of cendo lyteers and mecobalamin as well as regular check-up education. This case emphasizes the importance of early detection of papilledema through history taking, clinical examination, and fundoscopy to prevent permanent visual complications and determine comprehensive and timely management.

To analyze the effect of systemic steroid treatment in children with benign acquired isolated sixth nerve palsy (BAISNP) regarding healing, recurrence risk and late sequelae. A retrospective cohort design was used. The clinical database of a single medical center was reviewed for all children with BAISNP between 2016 and 2024. Data were collected as follows: demographics, age at initial presentation, complete eye and neurological examinations at presentation and every follow-up visit, neuroimaging and LP findings, treatments at presentation or for residual ocular misalignment, recovery periods and recurrences. Systemic steroids (1mg/kg/day oral prednisolone for 10 days) were recommended by certain physicians, to whom some patients were randomly assigned. Twenty-seven children were included in the study. Mean age at presentation was 2.6 ± 2.2 years with a follow-up of 2.0 ± 2.3 years. BAISNP completely resolved after 3.2 ± 3.1 months in all children. Nine children (33%) had a recurrence that resolved after 1.8 ± 0.7 months. Residual comitant esotropia (RCE) exceeding 10 prism diopters persisted in six children (22%) despite resolution of the abduction weakness. Three of them underwent surgery and none regained stereopsis. Fifteen children (56%) received systemic steroids upon presentation. Steroid treatment affected neither time to resolution nor recurrence rate. However, fewer children treated with steroids developed RCE (6% vs. 45%, p = 0.026). A multivariable analysis for RCE development found that only steroids had a statistically significant impact (β=-0.58, p = 0.006). Systemic steroids reduce the rates of RCE when administered during an acute episode of BAISNP.

Introduction: tuberculous meningitis is the most severe form of extrapulmonary tuberculosis, with mortality rates approaching 50%. Neurological damage is primarily driven by dysregulated host neuroinflammatory responses following the invasion of the central nervous system by Mycobacterium tuberculosis.Case report: A case is presented of a 45-year-old male, a former inmate, with a one-month clinical course characterized by constitutional symptoms, headache, and progressive neurological impairment. Physical examination revealed meningeal syndrome and sixth cranial nerve palsy. Cerebrospinal fluid analysis showed lymphocytic pleocytosis (410 cells/mm³, 88% lymphocytes), hyperproteinorrachia (260 mg/dL), and hypoglycorrachia (18 mg/dL). The diagnosis was confirmed via GeneXpert and neuroimaging, which evidenced basal leptomeningeal enhancement and hydrocephalus. Treatment was initiated with the HRZE regimen and adjuvant dexamethasone, achieving significant clinical improvement after 35 days of hospitalization. Discharge was coordinated to complete the total planned duration of antituberculous treatment through the Directly Observed Treatment, Short-course (DOTS/TAES) program. At the time of discharge, the patient was oriented and able to walk with minimal assistance, with the sixth cranial nerve palsy showing signs of progressive improvement.Conclusions: early diagnosis based on epidemiological and clinical suspicion is vital. Timely management with antitubercular drugs and corticosteroids significantly reduces mortality and permanent sequelae.

BACKGROUND AND OBJECTIVES: Macrovascular compression caused by a dolichoectatic vertebral or basilar artery represents a distinct subset of cranial nerve (CN) and brainstem compression disorders. Standard interpositional microvascular decompression (MVD) may not adequately decompress a large dolichoectatic vessel, necessitating vessel transposition. This study reports 2 decades of institutional experience with macrovascular decompression (MaVD) using a vascular mobilization and suture-pexy technique and evaluates long-term outcomes. METHODS: We retrospectively reviewed all patients undergoing MaVD for vertebrobasilar dolichoectasia-related brainstem or CN compression from 2005 to 2025. Demographics, clinical presentation, radiographic imaging, complications, and functional outcomes were analyzed. The operative technique involved mobilization of the offending large vessel and fixation to the clival dura using suture-pexy, and selective use of Teflon, fascia, or muscle interposition. Clinical outcomes were evaluated immediately postoperation, at 3 months, and/or at last follow-up. RESULTS: Among 144 patients treated for CN/brainstem compression syndromes, 22 (15%) had macrovascular causes. Patients (mean age 55 years; 73% men) presented mostly with hemifacial spasm (68%) or trigeminal neuralgia (23%). The vertebral artery was the offending vessel in 82% of patients, and compression occurred predominantly on the side of vertebral artery dominance. Brainstem compression was present in 32% (7/22). Complete symptom relief occurred in 86.5% (19/22) of patients immediately postoperation and 95% of patients at last follow-up (mean 1 year). There were no incidences of arterial dissection, stroke, or vessel occlusion. Complications included transient dysphagia (9%), taste disturbance (9%), hearing loss (5%), abducens palsy (5%), and pseudomeningocele (18%), two of which required cerebrospinal fluid diversion. CONCLUSION: MaVD using the suture-pexy technique is a safe and durable strategy for treating macrovascular CN and brainstem compression syndromes. This technique provides reliable decompression when standard MVD is inadequate.

Ophthalmic manifestations of Chiari malformation: a systematic review.

In this case report, we describe a 31-year-old female patient who presented with intermittent diplopia, progressive gait instability, dizziness and forgetfulness. Clinical examination revealed decreased level of consciousness (Glasgow Coma Scale score of 14), horizontal and vertical gaze-evoked nystagmus, bilateral abducens nerve palsy, and severe truncal and gait ataxia. Laboratory analyses did not reveal any diagnostic findings. Brain magnetic resonance imaging (MRI) showed bilateral FLAIR-hyperintensities in the dorsomedial thal-amus, mammillary bodies, and around the third ventricle extending into the quadrigeminal plate of the midbrain, findings indicative of Wernicke's encephalopathy. Given the patient's history of sleeve gastrectomy performed three months earlier, and the presumed thiamine (vitamin B1) deficiency due to malabsorption, reduced nutritional intake, and lack of micro-nutrient supplementation, the diagnosis of Wernicke's encephalopathy was established and high-dose intravenous thiamine therapy was initiated.

History A 76-year-old man presented to the emergency department with a 1-month history of worsening binocular diplopia on left horizontal gaze, along with 1 week of progressive dysarthria and dizziness. Additionally, he had a chronic history of right-sided cervicobrachialgia related to degenerative disk disease, which had been improving with oral analgesia. The patient's past medical history included hypertension, dyslipidemia, insomnia, and hypothyroidism. He also had postpolio syndrome affecting the right lower limb. He reported no fever, chills, cough, shortness of breath, abdominal pain, or chest pain. There was no history of rash, intravenous drug use, immunosuppressive medication use, or documented congenital abnormalities. He reported no recent or recurrent bacterial or viral infections. At clinical examination, the patient appeared tired and had a decreased level of alertness. He was hypertensive (165/91 mm Hg) but had a normal body temperature. Other vital signs were unremarkable. Neurologic assessment revealed left abducens nerve palsy, right lower facial palsy, horizontal nystagmus during right eye adduction, and right lower limb paresis with ipsilateral patellar hyperreflexia. Brain MRI performed the day after admission showed imaging abnormalities (Figs 1-3). Laboratory testing showed an elevated C-reactive protein level (135 mg/L; upper limit of normal, 1 mg/L); other blood tests were within normal limits. Extensive additional diagnostic workup-including serologic testing for anti-aquaporin-4 antibody, anti-DNA antibody, lupus anticoagulant, antinuclear antibody, anti-cardiolipin antibody, and rheumatoid factor-yielded negative results. Lumbar puncture revealed a normal cerebrospinal fluid opening pressure (18 cm H2O; upper limit of normal, 25 cm H2O). The cerebrospinal fluid was clear, with a normal total nucleated cell count (3.75/mm3; reference range, 0-5/mm3), normal glucose level (53 mg/dL [2.9 mmol/L]; reference range, 50-77 mg/dL [2.8-4.3 mmol/L]), and elevated total protein level (750 mg/L; reference range, 100-450 mg/L). Cerebrospinal fluid oligoclonal bands were positive.

Pituitary apoplexy, defined by an acute ischemic or hemorrhagic event of the pituitary gland, can lead to neurological deficits. We present the case of a 43-year-old male who initially exhibited symptoms resembling trigeminal autonomic cephalalgia (TAC) as sudden-onset headache, ptosis, and autonomic symptoms. He later developed abducens nerve palsy and magnetic resonance imaging revealed a pituitary macroadenoma with intratumoral hemorrhage. Endocrine evaluation showed multiple hormonal deficiencies. The patient was diagnosed with pituitary apoplexy and referred for surgical intervention. This case highlights the importance of considering pituitary apoplexy in the differential diagnosis of TAC-like presentations and emphasizes the importance of neuroimaging in patients presenting atypical headaches. Early recognition and appropriate management are crucial for optimizing outcomes in this potentially life-threatening condition.

Diplopia is an infrequent manifestation of GCA, but may precede other visual disturbances such as transient or permanent vision loss. The literature-pooled prevalence of diplopia in GCA patients stratified by cranial nerve (CN) involvement was assessed. The protocol was registered prospectively (PROSPERO: CRD420251071956). MEDLINE, Embase, and Cochrane CENTRAL databases were searched from inception to April 17, 2025. Studies were included if they reported on the proportion of diplopia events in patients with GCA. Literature screening, data extraction, and risk of bias (ROB) assessments were performed independently and in duplicate. A non-pairwise, random-effects meta-analysis was performed. 50 studies were included, encompassing 21,680 patients with GCA and 664 diplopia events. Overall, the pooled prevalence of diplopia in GCA patients was 7.15% (95% CI = 5.52-9.22%). The pooled prevalence of diplopia in GCA patients with CN III involvement was 0.96% (95% CI = 0.35-2.60%). The pooled prevalence of diplopia in GCA patients with CN IV involvement was 0.30% (95% CI = 0.07-1.26%). The pooled prevalence of diplopia in GCA patients with CN VI involvement was 1.41% (95% CI = 0.54-3.62%). Excluding studies with high risk of ROB, the pooled prevalence of diplopia in GCA patients was 7.14% (95% CI = 5.44-9.33%). Overall, 7.15% of patients with GCA experience diplopia, more frequently reported due to abducens nerve palsy compared to oculomotor and trochlear nerve palsies. Accordingly, new-onset binocular diplopia in adults may warrant consideration of GCA and further investigation. Future prospective studies should aim to better characterise underlying aetiologies and assess whether early recognition of diplopia translates to improved visual prognosis.

Giant intracranial aneurysms are rare, with those loca­ted in the petrous segment of the internal carotid ar­tery being even less common. These aneurysms may cause neurological deficits due to mass effect on adjacent structures, especially cranial nerves. We present a case of a 60-year-old woman with persistent headaches and binocular diplopia. Neurological examination revealed isolated left abducens nerve palsy. Imaging identified a 25 mm partially thrombosed saccular aneurysm at the lacerum-cavernous segment of the left internal carotid artery. Given the symptomatic presentation and risk of progression, the patient underwent successful endovas­cular embolization with a flow-diverter stent and coils, resulting in marked symptom improvement. This case highlights the importance of considering internal carotid artery aneurysms in patients with cranial nerve palsies. Early imaging and timely endovascular intervention can prevent irreversible neurological damage and signifi­cantly improve clinical outcomes.

Isolated third, fourth, and sixth cranial nerve palsies (CNP) in elderly people occur commonly due to microvascular ischemia. Ischemic isolated CNP share several atherosclerotic risk factors that are responsible for stroke which include hypertension, diabetes mellitus and dyslipidemia. Hyperhomocysteinemia is atherogenic and hence is also considered as an independent risk factor for stroke. So indirectly, elevated homocysteine in CNP may act as a risk factor for stroke. To determine the incidence of isolated ischemic CNP secondary to elevated serum homocysteine (predisposing them to a greater risk of stroke), and if serum homocysteine levels need to be checked routinely in all isolated CNP by neuro-ophthalmologists. This is a retrospective case study, in which 66 patients diagnosed with ischemic isolated CNP were enrolled. Informed written consent was obtained from all who participated in this study. Data of these patients were collected from the electronic medical records and were analyzed. Complete anterior, posterior segment and neuro-ophthalmic examinations were done, in addition to routine blood investigations and serum homocysteine. The mean age was 55 years old. Gender wise, 74.24% affected were males and 25.76% were females. The sixth nerve was affected in 68.18% cases. Of 66 patients, 37 cases (56.06%) had elevated serum homocysteine. In patients > 40 years and without any systemic risk factors, 63.2% had elevated serum homocysteine. In patients < 40 years and without systemic risk, 66.7% had high serum homocysteine levels. In cases without systemic risk factors, serum homocysteine may indirectly act as a risk factor for developing stroke in patients having isolated ischemic CNP. According to our study, patients with or without risk factors and those above 40 years, 56.06% patients with isolated ocular motor palsy had elevated serum homocysteine. This implies that the level of elevated serum homocysteine was statistically significant (P < 0.05) in these patients; thus, indirectly showing a greater predilection towards developing a stroke. In this small pilot study, we show that even in neuro-ophthalmology serum homocysteine should be routinely checked for all patients with isolated ischemic CNP. This might reduce the incidence of patients developing a stroke.

International consensuses and guidelines on clinical practices on abducens nerve palsy by the Asia-Pacific Strabismus and Pediatric Ophthalmology Society (APSPOS) and the Academy of Asia-Pacific Professors of Ophthalmology (AAPPO).

Spontaneous intracranial hypotension (SIH) with the formation of a spinal longitudinal epidural collection (SLEC) is an important treatable cause of headache. Left untreated, neurological sequelae can include cranial neuropathy, superficial siderosis and brain-sagging dementia. We describe a male in his late 40s presenting with orthostatic low-pressure headache and binocular horizontal diplopia due to an isolated left abducens nerve palsy, a recognised false localising sign. Imaging revealed intracranial hypotension associated with a SLEC, attributed to a cervical osteophyte associated dural tear. An empirical lumbar epidural blood patching led to rapid clinical improvement and radiological resolution of the SLEC on follow-up imaging. This case highlights that abducens nerve palsy, traditionally considered a false localising sign of raised intracranial pressure, can occur in low-pressure states. Spinal imaging is crucial for identifying SLEC and guiding management, enabling prompt treatment to prevent severe neurological outcomes. We also review the causes, diagnosis and management of SIH.

Abducent nerve palsy as a rare sequela of temporal bone fracture: A case report

Background Isolated lateral rectus (LR) palsy is a common cranial nerve palsy with a variety of causes. Horizontal diplopia is frequently caused by isolated LR palsy, a common cranial nerve palsy in adults. The abducens nerve is vulnerable to a variety of vascular, inflammatory, traumatic, viral, and compressive diseases because of its lengthy intracranial journey. This study aims to describe the clinical profile, etiological distribution, and outcomes in adults with isolated LR palsy. Methodology This retrospective observational study included 29 consecutive adults diagnosed with isolated LR palsy. Demographic characteristics, clinical presentation, investigation findings, etiological diagnoses, and recovery outcomes during follow-up were systematically recorded and analyzed using descriptive statistical methods. Results The mean age was 48.17 years (range = 19-85 years), with a male-to-female ratio of 15:14. Etiologies included diabetes-related microvascular ischemia in seven (24.1%) patients, hypertension-related microvascular ischemia in seven (24.1%) patients, infection with inflammation in four (13.8%) patients, trauma in four (13.8%) patients, idiopathic causes in two (6.9%) patients, tumor in one (3.4%) patient, cavernous sinus thrombosis in three (10.3%) patients, and microvascular ischemia associated with both diabetes mellitus and hypertension in one (3.4%) patient. At the last follow-up, 19 (65.5%)patients had complete recovery, two (6.8%) had partial recovery, one (3.4%) had no recovery, and seven (24.1%) were lost to follow-up. Conclusions Microvascular ischemia associated with diabetes mellitus and hypertension was the leading cause of isolated LR palsy in adults. Most patients demonstrated improvement during follow-up, whereas traumatic and compressive etiologies showed relatively poorer outcomes. Careful systemic evaluation and targeted neuroimaging are important in patients with atypical presentations or suspected non-microvascular causes. These findings emphasize the importance of systematic clinical assessment, etiological evaluation, and follow-up in adults presenting with isolated LR palsy.

MENINGITIS CAUSED BY CRYPTOCOCCUS GATTII IN A PERSON LIVING WITH HIV: A CASE REPORT OF REFRACTORY INTRACRANIAL HYPERTENSION AND LIMITED ACCESS TO NEUROSURGICAL MANAGEMENT IN THE BRAZILIAN PUBLIC HEALTH SYSTEM