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Cureus Jan 2024One-and-a-half syndrome (OHS) is a horizontal gaze palsy in one direction with internuclear ophthalmoplegia (INO) in the other. The only eye movement possible is the...
One-and-a-half syndrome (OHS) is a horizontal gaze palsy in one direction with internuclear ophthalmoplegia (INO) in the other. The only eye movement possible is the abduction of the contralateral eye with nystagmus. The usual structures affected are the medial longitudinal fasciculus and paramedian pontine reticular formation or the abducens nucleus. Most commonly, the OHS is caused by ischemia and demyelinating lesions. The other causes include infectious, neoplastic, and rarely traumatic. We report a case of a 42-year-old non-compliant hypertensive female who presented with giddiness, projectile vomiting, and right-sided hemiparesis and was found to have OHS on cranial nerve examination in the emergency department (ED). In the ED, the presence of complete horizontal gaze palsy in one direction with INO in the other direction should raise suspicion of a brainstem pathology.
PubMed: 38425582
DOI: 10.7759/cureus.53193 -
Journal of AAPOS : the Official... Apr 2024Duane retraction syndrome (DRS) is a rare congenital nonprogressive restrictive strabismus. The absence/hypoplasia of the abducens nerve and the aberrant innervation of...
Duane retraction syndrome (DRS) is a rare congenital nonprogressive restrictive strabismus. The absence/hypoplasia of the abducens nerve and the aberrant innervation of the lateral rectus muscle by the oculomotor nerve have been hypothesized as causes of DRS, although the phenomenon of globe retraction can also occur in the setting of mechanical factors, such as congenital abnormal orbital structures or orbital trauma. We present the cases of 2 DRS patients with absent abducens nerve and abnormal muscular bands connecting the superior rectus and inferior rectus muscles on the temporal side of the optic nerve.
Topics: Humans; Duane Retraction Syndrome; Oculomotor Muscles; Strabismus; Oculomotor Nerve; Eye Injuries
PubMed: 38417542
DOI: 10.1016/j.jaapos.2024.103855 -
The New England Journal of Medicine Feb 2024
Topics: Aged; Female; Humans; Abducens Nerve Diseases
PubMed: 38416433
DOI: 10.1056/NEJMcpc2312740 -
The Journal of Emergency Medicine Mar 2024This case report describes a 34-year-old woman who developed diplopia and strabismus 2 weeks after a vaginal delivery and epidural anesthesia.
BACKGROUND
This case report describes a 34-year-old woman who developed diplopia and strabismus 2 weeks after a vaginal delivery and epidural anesthesia.
CASE REPORT
A 34-year-old women presented to the emergency department (ED) with continued headache and new-onset diplopia after having undergone epidural anesthesia for a vaginal delivery 2 weeks prior. During that time, she underwent two blood patches, rested supine, drank additional fluids, and consumed caffeinated products for her spinal headache. When she developed double vision from a cranial nerve VI palsy, she returned to the ED. At that time, she had a third blood patch performed, and she was evaluated by a neurologist. The medical team felt the cranial nerve VI palsy was due to the downward pull of the brain and stretching of the nerve. Magnetic resonance imaging and neurosurgical closure of the dura were considered as the next steps in treatment; however, they were not performed after being declined by the patient. All symptoms were resolved over the next 3 weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the uncommon complication of a cranial nerve VI palsy from a persistent cerebrospinal fluid leak after a dural puncture. Emergency physicians must be aware that diplopia can be a rare presenting symptom after patients undergo a lumbar puncture. Furthermore, emergency physicians should be aware of the multiple treatment options available. Knowledge of the timeline of resolution of the diplopia is necessary to make shared decisions with our patients about escalating care.
Topics: Humans; Female; Adult; Diplopia; Blood Patch, Epidural; Anesthesia, Epidural; Abducens Nerve Diseases; Headache; Paralysis; Cranial Nerves
PubMed: 38413284
DOI: 10.1016/j.jemermed.2023.11.006 -
International Journal of Surgery Case... Mar 2024Breast cancer, comprising 25 % of all diagnosed cancers, predominantly affects women globally. While bone metastasis is common, occurrences at the clivus or skull base...
INTRODUCTION
Breast cancer, comprising 25 % of all diagnosed cancers, predominantly affects women globally. While bone metastasis is common, occurrences at the clivus or skull base are rarely documented. Treatment varies from surgery in early stages to a multifaceted approach for advanced cases, incorporating chemotherapy, radiotherapy, and surgery based on staging and histology.
CLINICAL PRESENTATION
A 40-year-old female presented with a rapidly enlarging lump in her left breast and diplopia on right gaze. Histology was positive for invasive breast cancer (no special type) and Contrast-Enhanced Computed Tomography demonstrated metastatic deposits in multiple vertebrae and bilateral ilium. Further, magnetic resonance imaging of the brain and orbits revealed metastatic deposits in the clivus which extended up-to medial wall of the cavernous sinus, causing compression of the right abducens nerve. Multidisciplinary Tumor Board review recommended chemoradiotherapy.
DISCUSSION
Metastases from breast cancer can occur locally or to distant sites like lymph nodes, bones, lungs, liver, and brain. Unusual symptoms, such as new-onset diplopia, trigger further investigation. Although bone metastases occur in 50-65 % of cases, clivus metastasis is rare. Treatment aims at extending survival, symptom management, and enhancing quality of life through chemotherapy and radiotherapy. Outcomes hinge on metastatic burden and regional therapy responsiveness. Distant metastases substantially reduce the 5-year survival rate from 80 % to approximately 25 %, but cases often improve with regional interventions.
CONCLUSION
Although an extremely rare occurrence, clivus metastasis might be considered in patients with a history of malignancy, in particular, breast malignancy, presenting with new-onset sixth nerve palsy.
PubMed: 38412597
DOI: 10.1016/j.ijscr.2024.109437 -
Archivos de La Sociedad Espanola de... May 2024Ocular neuromyotonia (ONM) is an infrequent disorder characterised by recurrent episodes of binocular diplopia caused by paroxysmal contraction of one or several...
Ocular neuromyotonia (ONM) is an infrequent disorder characterised by recurrent episodes of binocular diplopia caused by paroxysmal contraction of one or several extraocular muscles innervated by the same cranial nerve. It can be triggered spontaneously or caused by prolonged contraction of specific eye muscle(s) and is usually related to a local intracranial radiotherapy antecedent. We report the case of a 46-year-old woman who developed intermittent episodes of binocular diplopia eight years after radiotherapy for a nasopharyngeal carcinoma. After a complete neuro-ophthalmic assessment we diagnosed the case as an abducens nerve neuromyotonia. Although it is infrequent, radiotherapy to the nasopharynx is a possible cause of ONM, due to the proximity to the base of the skull and extraocular motor nerve pathways, especially that of the VI cranial nerve, as is the case presented in this article, about a patient whose history is a nasopharyngeal carcinoma treated with local radiotherapy.
Topics: Humans; Female; Middle Aged; Nasopharyngeal Neoplasms; Isaacs Syndrome; Nasopharyngeal Carcinoma; Diplopia; Carcinoma; Abducens Nerve Diseases; Radiation Injuries; Radiotherapy
PubMed: 38401598
DOI: 10.1016/j.oftale.2024.01.017 -
Journal of Hematopathology Mar 2024A 22-year-old man presented at the emergency department with progressive headache, vomiting and horizontal diplopia over 2-month period. He also developed blurred vision...
A 22-year-old man presented at the emergency department with progressive headache, vomiting and horizontal diplopia over 2-month period. He also developed blurred vision in his left eye. He complained of loss of appetite for the past 2 months, resulting in a 5-kg weight loss. Examination upon arrival revealed papilledema and bilateral abducens nerve palsy. Motor and sensory functions were intact. Magnetic resonance imaging (MRI) of the brain revealed multiple extra-axial nodular enhancing lesions with size of 5-10 mm mainly along with both sides of falx cerebri and vasogenic brain oedema (Fig. 1). Stereotactic brain biopsy was performed to obtain tissue diagnosis. Histologic examination revealed brain infiltration by few atypical cells hidden amongst abundant and mixed population of inflammatory cells including lymphocytes and histiocytes. The atypical cells are large cells with horseshoe nuclei (red arrow; Fig. 2A ×100 and Fig. 2B ×400). Immunohistochemistry showed strong, uniform CD30 expression (Fig. 2C ×400) and cytoplasmic ALK staining (Fig. 2D ×400), as well as for CD3 (Fig. 2E ×400) and CD68 (Fig. 2F ×400). B-cell markers (CD20) were negative (Fig. 2G ×400).
Topics: Humans; Male; Young Adult; Brain; Brain Edema; Central Nervous System; Dura Mater; Lymphoma, Large-Cell, Anaplastic
PubMed: 38376722
DOI: 10.1007/s12308-023-00570-7