Abducens Research Articles

Cranial nerve palsies and intracranial aneurysms: A narrative review of patterns and outcomes.

Cranial nerve palsy (CNP) in patients with intracranial aneurysms (IAs) can impose significant burdens on a patient's quality of life. The literature has a paucity of reviews addressing patterns of overall reported cranial nerve (CN) involvement and outcomes in patients with IA. The literature systematically reviewed CNP at presentation in the setting of IA using PubMed, Web-of-Science, and Scopus according to the PRISMA guidelines. Fifty-two studies reported a total of 513 patients with IA and 630 CNPs observed at presentation: oculomotor (58.25%), abducent (15.87%), optic (12.06%), trochlear (8.7%), and trigeminal (1.9%). Most common aneurysms are located in a posterior communicating artery (46%) and cavernous internal carotid artery (29.2%). Trends of CNP based on the rupture status of IAs showed that 80% were associated with unruptured IAs and 20% with ruptured IAs. Post-treatment of IA, 55% of patients had complete resolution of CNP, with most (89%; n = 134) resolving within the first 6 months. Stratified by CNP type: Complete resolution rate is 100% in CN VII-IX, 60% in CN VI, 59% in CN IV, 54% in CN III, 45% in CN V, and 43% in CN II. In patients with cranial nerve palsies attributed to IAs, the location and rupture status of the aneurysm could determine the type and severity of the nerve palsy. Most patients experienced favorable outcomes in terms of their resolution and long-term function of the CNP after treatment of the IA.

Establishing the Precise Location of Apanga Marma and defining its Structural Component through Cadaveric Study

Background: Apanga marma is a Jatrurdhwagata marma that is positioned within half angula dimension below the tail end of the eyebrow and outer to the lateral canthus of the eye. Its injury causes andhya and dristiupaghata. Sushruta classifies it as Sira structurally, however Vagbhata classifies it as Snayu marma. The precise position, radiance, and conflicts in opinion in identifying the structural entity and applied importance of this marma must be clarified. The objective of this study was to locate and ascertain the position and structural entity of Apanga marma. Materials and Methods: Study was conducted in two steps: Conceptual study by reviewing the literatures and cadaveric observational study by dissection over 4 cadavers. Results and Discussion: The Apanga marma was discovered to be positioned on the anterior section of the superior temporal fossa, near the lateral canthus of the eye. Extracranial, intracranial, and intraorbital neurovascular structures were observed within the designated area. Structures in the area include the Middle cerebral artery, the Middle meningeal artery, and the Abducent nerve, which can cause visual problems or total blindness if injured. Conclusion: Apanga marma was found to be located in the anterior section of the superficial temporal fossa, lateral to the lateral orbital edge, beneath the tail end of the eyebrow, and above the zygomatic arch. The middle meningeal and middle cerebral arteries were discovered as a specific anatomical entity in the marma area, resulting in blindness or vision impairment upon injury.

Microsurgical Procedures of Microvascular Decompression for Trigeminal Neuralgia

Microvascular decompression for trigeminal neuralgia was successfully performed following the secure surgical steps. The most crucial step involves creating a safe operative field in the dural opening. The petrotentorial junction should be identified without cerebellar retraction before proceeding to the deeper areas. Dissecting the petrosal vein and opening the horizontal fissure contributed to the expansion of the operative field. Bleeding often occurs from the dorsal cerebellar bridging vein and junction of the petrosal vein into the superior petrosal sinus. Transposition of the most common offenders, the superior and anterior inferior cerebellar arteries, is effectively achieved by dissecting both the proximal and distal sides of the neurovascular compression site. Teflon should be placed at a sufficient distance to prevent contact with the nerve, which can lead to recurrence. Treating vertebrobasilar artery-related cases is challenging and involves the risk of cranial nerve injuries. Multiple offending vessels are commonly involved. In such cases, it is essential to be aware of the course of the trochlear and abducens nerves during decompression. Applying the most effective and least risky maneuver is necessary for treating cases involving the vertebrobasilar artery.

A Case of Neurosyphilis Presenting with Isolated Abducens Nerve Palsy.

We herein report a case of neurosyphilis that presented with isolated bilateral abducens nerve palsy. A 39-year-old man was referred to our department with diplopia. He had a history of homosexual relationships and showed only bilateral abducens nerve palsy upon a neurological examination. Positive syphilis tests in the serum and cerebrospinal fluid and a contrasting effect on the abducens nerve on magnetic resonance imaging (MRI) confirmed the diagnosis of active neurosyphilis. When a patient manifests isolated abducens nerve palsy, neurosyphilis can be a differential diagnosis, although rare, and contrast-enhanced MRI may help diagnose the disease.

Retrobulbar haemorrhage and globe perforation after botulinum toxin injection into the medial rectus

Aims/Purpose: The aim of this communication is to show a recent case of both retrobulbar haemorrhage (RH) and probable globe perforation (GP) after botulinum toxin (BT) injection in the medial rectus of the right eye.Methods: We selected a recent case seen at our hospital. A 5u BT injection was performed under topical anaesthesia and guiding electromiography into the medial rectus due to a VI cranial nerve palsy. 2 min later the patient claimed intense pain and we evidenced a sudden growing periocular oedema and progressing exophthalmos. Retrobulbar haemorrhage was diagnosed and immediate canthotomy and cantholisys were performed, with consequent haemorrhage drainage. In the 24 h follow‐up visit, our patient claimed blurry vision and floaters. VA RE was 0.3 (before BT 0.7). Important corneal oedema and 3–4 + tyndall was observed. In the funduscopic exploration severe hemovitreous was observed; and an ocular ecography was performed, which showed no signs of retinal disruption. As vitreous started clearing and VA and floaters improved, observational treatment was decided. When we became able to see the retina with detail a possible perforation hole was seen in the infero‐medial quadrant, with no signs of traction or retinal elevation.Results: 3 months later, VA was 0.8 e° 1. Funduscopy showed an applied retina, with only a few persistent fibrine remainders in the inferior quadrant. Good‐coloured optic disc, with physiologic excavation and no signs of atrophy.Conclusions: Eventhough RH and GP are quite rare complications after BT infection, we should always take them into consideration. We also wanted to highlight these complications treatment. RH: Immediate canthotomy and cantholysis must be performed GP: close observation must be followed in order not to miss a retinal detachment. Plus, to avoid them we should be careful to perform the right technique and to use the electromiograph to guide us into the muscle.

Vogt‐Koyanagi‐Harada‐like findings as the first manifestation of neuroleukaemia

Aims/Purpose: To report a well‐documented case of a 62‐year‐old woman presenting with VKH‐like findings as the first manifestation of neuroleukaemia.Methods: Case study.Results: A 52‐year‐old woman who had received a diagnosis of acute myeloid monoblastic leukaemia (AML) one month prior and was in remission after the induction phase presented with floaters and gradual visual loss in both eyes. Visual acuity was 20/200 and 20/25, respectively. Anterior segment exam was normal in both eyes. Funduscopy showed reduced foveal reflex. On spectral‐domain OCT, subretinal fluid was found in both eyes. Fluorescein angiography showed hypofluorescent areas compatible with multifocal serous retinal detachments and multiple hyperfluorescent dots surrounding the detached areas. Days after, the patient debuted with facial palsy and binocular diplopia due to bilateral VI cranial nerve (CN) palsy, left VII CN palsy and right complete III CN palsy. An MRI was performed with no signs of infiltration. A cerebrospinal fluid sample was drawn by lumbar puncture and its analysis denoted infiltration of AML cells with similar immunophenotype to that on initial bone marrow biopsy. Our patient presented with an atypical case of Vogt‐Koyanagi‐Harada (VKH) with multiple leakages along the periphery of the detached retinal area. This sparing of the macula should be considered a suspicious pattern, and combined with the finding of CN palsies was enough to suspect a relapse in the form of CSF infiltration, making the diagnosis of neuroleukaemia possible.Conclusions: Exudative retinal detachment can be a primary presentation of AML or denote a relapse. VKH is a diagnosis of exclusion, as one of the main criteria for its diagnosis is the absence of other systemic diseases. This becomes especially important in atypical presentations and older patients. So as not to miss life‐threatening underlying conditions, leukaemia and lymphoma should be considered in the differential diagnosis of VKH.

Outcomes and Factors Associated with Successful Strabismus Surgery for Abducens Nerve Palsies: A Retrospective Study and Literature Review [Response to Letter

Outcomes and Factors Associated with Successful Strabismus Surgery for Abducens Nerve Palsies: A Retrospective Study and Literature Review [Response to Letter

Diplopia as the presenting symptom of a post‐transplant lymphoproliferative disorder in a bilateral inferior lim transplanted young adult

Aims/Purpose: To present a unique case of post‐transplant lymphoproliferative disorder (PTLD) after bilateral inferior limb transplantation, which is still controversial due to the absence of precedents in the literature and the unclear risk–benefit ratio.Methods: Case report.Results: A 22‐year‐old male presented to the emergency room complaining of double vision. He had a history of bilateral inferior limb amputation 8 years ago and received a bilateral lower limb transplantation 2 years later. He had normal graft function and was receiving cytomegalovirus prophylaxis. During neurological examinations left abducens nerve (CN VI) palsy was noted. Other cranial nerves affected produced facial hypoesthesia (CN V) and mild paresis (CN VII), hearing loss and tinnitus in left side (CN VIII) and soft palate asymmetry (CN X). He was otherwise neurologically intact, alert and orientated. MRI revealed a lesion located at the facial colliculus at the floor of 4th ventricle. In the context of immunosuppression, the differential diagnosis included abscess versus PTLD. Biopsy of the lesion was performed. Morphologically atypical lymphocytic cells suggestive of B lymphoma were identified. Monoclonal rearrangement for heavy chain Igen and immunoglobulins were identified with molecular biology techniques. The histology features were consistent with a diagnosis of CNS B lineage primary lymphoma. Two days later, bilateral supracondylar amputation was performed. Following the explant, immunosuppression was withdrawn. His underlying condition was finally diagnosed as PTLD, for which he started a chemotherapeutic regimen with radical intention (methotrexate and cytosine arabinoside). The patient recovered fully and up to date, 10 years later, is doing well.Conclusions: Due to its diverse aetiologias, a proper workup must be done of the patients presenting with diplopia to the emergency room. PLTD must be a condition to always be considered in patients with history of solid organ transplant; since the early diagnosis is crucial for a successful management of this often‐fatal condition.

Isolated Abducens Nerve Palsy: A Rare Manifestation of Recurrent Extramedullary Myeloma

Isolated Abducens Nerve Palsy: A Rare Manifestation of Recurrent Extramedullary Myeloma

Abducens palsy with facial nerve palsy: A rare clinical presentation

Abstract Multiple cranial nerve palsies are commonly due to brainstem lesions and the presence of abducens nerve palsy with peripheral facial nerve palsy is very rare and the exact etiologies are not defined. Very few reports of pontine infarct are associated with the condition. We report a young male presented with sudden onset diplopia with left-side abduction deficit and inadequate eyelid closure of the left eye. Upon evaluation, it was found to have high blood pressure recordings and imaging revealed the presence of an ipsilateral pontine infarct. The patient was managed with antihypertensives and antiplatelet agents and symptomatic resolution was found after 2 months of follow-up. This report describes a very rare association of abducens and facial nerve palsy in pontine infarct and to our best knowledge only a few reports are available on the same.

Abducens Nerve Palsy as the Only Presenting Symptom for Solitary Cerebellar Tuberculoma in an Immunocompetent Young Adult

Abducens Nerve Palsy as the Only Presenting Symptom for Solitary Cerebellar Tuberculoma in an Immunocompetent Young Adult

Parkinson’s syndrome – The syndrome within a syndrome – A case report

Horner’s syndrome is caused by damage to the sympathetic pathway anywhere along its course. The unique association of the sixth nerve palsy with ipsilateral Horner’s syndrome has a localizing value, known as Parkinson’s syndrome. The patient described here had left ptosis, miosis of pupil, and abduction limitation on left gaze. A diagnosis of Parkinson’s syndrome was made. Magnetic resonance angiography confirmed a cavernous lesion. High suspicion is essential for diagnosis of such a variant of Horner’s syndrome.

An overview of neuro-ophthalmic disorders at Jenna Ophthalmic Center, Baghdad, Iraq (2021-2022).

Neuro-ophthalmic disorders are often documented individually for each illness, with little data available on their overall incidence and pattern. The overall incidence of neuro-ophthalmic illnesses in Iraq is still not recorded. This study aimed to evaluate the clinical, demographic, and etiological features of patients seeking consultation at an Iraqi neuro-ophthalmology clinic. A prospective cross-sectional observational research was conducted at the Janna Ophthalmic Center in Baghdad, Iraq. The center serves a diverse patient population from various governorates. All newly diagnosed patients with neuro-ophthalmic disorders who visited the neuro-ophthalmological clinic, regardless of gender or age group, were included. The neuro-ophthalmologist established a diagnosis for each case by reviewing the patient's medical history, doing physical examinations, administering specific tests, and, in certain cases, using neuroimaging methods. The duration of the study was extended from March 2021 to November 2022. Among the 6440 patients evaluated, 613 cases were confirmed at the neuro-ophthalmology clinic. Ischemic optic neuropathy (NAION, AION, and PION) was the most prevalent diagnosis, accounting for 17.61% of newly reported cases in the field of neuro-ophthalmology. This was followed by sixth nerve palsy. Diabetes mellitus affected 42.7% of the cases, followed by hypertension, which affected 39.3% of the participants. The incidence of neuro-ophthalmic diseases tended to be high. Ischemic optic neuropathy and sixth nerve palsy, traumatic/compressive optic neuropathy, and papilledema were the most common neuro-ophthalmic disorders reported.

Neuroanatomy of lumbosacral and pudendal plexus in pigeon of Bangladesh

The present study aims to reveal the neuroanatomy of the lumbosacral and pudendal plexus in pigeons of Bangladesh. Six adult male domesticated pigeons were used in this study. The body cavities of the pigeons were opened after the administration of the anesthetics. The nerve roots of the plexus were dissected separately and photographed. We found that the lumbosacral plexus consisted of the lumbar plexus and the sacral plexus. The lumbar plexus was formed by the union of the ventral branches of the first, second, and third lumbar (L1-L3) spinal nerves. The lumbar plexus was branched into cutaneous femoris nerve, coxalis cranialis nerve, femoralis nerve, saphenous nerve, and obturatorius nerve. The sacral plexus was formed by the union of the ventral branches of the fourth lumbar and first, second, third, and fourth sacro-coccygeal spinal nerves. The sacral plexus gives off a large sciatic nerve and innervated as tibial and fibular nerve into musculature of the hind limb of the pigeon. The pudendal plexus was organized from the fourth, fifth, sixth and seventh sacro-coccygeal spinal nerves and were innervated into the tail region of the domesticated pigeons. This study was the first investigation of lumbosacral and pudendal plexus in domesticated pigeons and the results may serve as a basis for further investigation in other species. Bangladesh Journal of Animal Science 52 (4): 98-104

Neuroanatomy of lumbosacral and pudendal plexus in pigeon of Bangladesh

The present study aims to reveal the neuroanatomy of the lumbosacral and pudendal plexus in pigeons of Bangladesh. Six adult male domesticated pigeons were used in this study. The body cavities of the pigeons were opened after the administration of the anesthetics. The nerve roots of the plexus were dissected separately and photographed. We found that the lumbosacral plexus consisted of the lumbar plexus and the sacral plexus. The lumbar plexus was formed by the union of the ventral branches of the first, second, and third lumbar (L1-L3) spinal nerves. The lumbar plexus was branched into cutaneous femoris nerve, coxalis cranialis nerve, femoralis nerve, saphenous nerve, and obturatorius nerve. The sacral plexus was formed by the union of the ventral branches of the fourth lumbar and first, second, third, and fourth sacro-coccygeal spinal nerves. The sacral plexus gives off a large sciatic nerve and innervated as tibial and fibular nerve into musculature of the hind limb of the pigeon. The pudendal plexus was organized from the fourth, fifth, sixth and seventh sacro-coccygeal spinal nerves and were innervated into the tail region of the domesticated pigeons. This study was the first investigation of lumbosacral and pudendal plexus in domesticated pigeons and the results may serve as a basis for further investigation in other species. Bangladesh Journal of Animal Science 52 (4): 98-104

Abducens Nerve Palsy - A Rare Complication of Spinal Cord Stimulator Insertion: Case Report and Literature Review

BACKGROUND: Spinal cord stimulation (SCS) is an emerging therapeutic intervention for intractable chronic pain. However, SCS surgery is not exempt from complications such as lead migration, infections, hardware malfunction and neurological deficits. CASE REPORT: We present this case report on bilateral abducens nerve palsy, as a rare iatrogenic complication of SCS system insertion in a 65-year-old man with intractable chronic pain. After failing conservative treatment and explant, he underwent corrective strabismus surgery and achieved symptom control. CONCLUSION: The case presents a diagnostic and management challenge due to the nature of his presentation, neuroimaging pitfalls and limited high-quality evidence for management. We recognise cranial nerve palsy as a potential, yet real, complication of SCS surgery, of which abducens nerve palsy presents significant detriment to patients lives. As SCS continues to expand in clinical practice, inevitably, so will its iatrogenic sequela signalling the need for greater recognition and formation high-quality evidence for efficacious management. KEY WORDS: Spinal cord stimulation insertion, abducens nerve palsy, chronic pain, case report

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

Abducens Nerve Palsy Caused by Cavernous Sinus Meningioma Mimicking Tolosa-Hunt Syndrome

Purpose: To report a case of abducens nerve palsy caused by cavernous sinus meningioma mimicking Tolosa-Hunt syndrome (THS).Case summary: A 59-year-female visited to the ophthalmic department for sudden onset of horizontal diplopia for 20 days. The extraocular examination showed 10 prism diopters (PD) esotropia at distant fixation and ortho at near fixation without definitive abduction limitation. At 2 months of follow-up, she showed the 25 PD left esotropia with abduction limitation of the left eye. The ocular pain and headache were newly developed. Magnetic resonance imaging (MRI) with contrast was performed and revealed the enlargement and enhancement of left cavernous sinus. THS was suspected and high dose steroid treatment was performed. The ocular findings and headache were improved after treatment. These symptoms showed waxing and waning with steroid tapering during follow-up. The follow-up MRI showed no definitive improvement of cavernous sinus lesion compared with previous study. The cavernous sinus meningioma was considered. There was no improvement of ocular motility findings during follow-up and the strabismus surgery was performed.Conclusions: The abducens nerve palsy with headache can occur caused by cavernous sinus meningioma. It may be difficult to differentiate it from THS in certain cases.

Botulinum Toxin Injection for the Treatment of Third, Fourth, and Sixth Nerve Palsy: A Meta-Analysis.

The efficacy of botulinum toxin injection for the treatment of third, fourth, and sixth nerve palsy was evaluated. PubMed, Scopus, EMBASE, Web of Science, and Google Scholar databases were searched. Data about the duration of palsy (acute vs chronic), cause of the palsy, type of toxin used, mean dose, and other background characteristics were collected. Outcome variables were success rate (defined by alleviation of diplopia or reduction in eye deviation) and standardized mean difference of prism diopter and abduction deficit before and after injection. The Joanna Briggs Institute checklist was implemented for the risk of bias assessment. The analysis included 38 articles, comprising 643 patients. The overall treatment success rate in acute and chronic nerve palsy was 79% and 33%, respectively. The success rate was not significantly different between different subgroups of age, type of botulinum toxin, pre-injection prism diopter, etiology of the palsy, duration of follow-up, and mean dose of botulinum toxin injection. However, in both acute and chronic palsy, diabetes etiology was accompanied by the highest success rate. Overall symptomatic response to botulinum injection was 84% (95% CI: 67% to 96%), whereas functional response was observed in 64% (95% CI: 47% to 79%) of the patients. The odds ratio for the success rate of treatment of palsies with botulinum toxin versus expectant management was 2.67 (95% CI: 1.12 to 6.36) for acute palsy and 0.87 (95% CI: 0.17 to 4.42) for chronic palsy. Botulinum toxin can be used for the treatment of acute third, fourth, and sixth nerve palsy, especially in patients with acute palsy and more severe tropia. [J Pediatr Ophthalmol Strabismus. 2024;61(3):160-171.].

Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia

Background Tolosa-Hunt syndrome is a rare neuroinflammatory disease that affects the cavernous sinus and superior orbital fissure, resulting in symptoms of neuropathy. Case presentation We report a case of a 35-year-old male patient with no past medical history who presented to the emergency department (ED) complaining of a four-day history of progressively increasing headaches associated with right eye pain and double vision. A physical examination showed findings suggestive of abducens nerve palsy. A computed tomography (CT) scan showed subtle asymmetric thickening of the right cavernous sinus, which prompted further investigation by magnetic resonance imaging (MRI) scan. The MRI scan showed intensely enhanced soft tissue thickening in the right cavernous sinus region, slightly extending to the right orbital apex, which caused enlargement of the cavernous sinus and appeared isointense to the adjacent muscles on T1 and T2. The diagnosis of Tolosa-Hunt syndrome was made after the exclusion of all other possible pathologies. The patient received prednisolone therapy; his symptoms improved, and he was discharged after three days. Two weeks later, the patient presented again to the ED with the same symptoms and was treated symptomatically. Conclusions This case highlights a very rare etiology for painful ophthalmoplegia, which is Tolosa-Hunt syndrome. Thickening of the cavernous sinus on MRI images with a background history of painful ophthalmoplegia and headache should raise clinician’s suspicion towards the disease. In addition, exclusion of other possible causes is very important, as Tolosa-Hunt syndrome is a diagnosis of exclusion.