-
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 -
Journal of Neurosurgery Jul 2024The authors performed a further in-depth study of the lateral compartment of the cavernous sinus (LCCS) by the endoscopic endonasal approach to improve the safety and...
OBJECTIVE
The authors performed a further in-depth study of the lateral compartment of the cavernous sinus (LCCS) by the endoscopic endonasal approach to improve the safety and efficacy of the lateral approach for the removal of Knosp grade 4 pituitary adenomas (KG4PAs).
METHODS
Twenty-three cadaveric specimens were used for endoscopic endonasal dissection, and the LCCS was exposed to observe the neurovascular and fibrous structures within. A subclassification of the lateral approach based on further knowledge of the LCCS was proposed and used to resect 86 KG4PAs, and the surgical outcomes of these cases were reviewed. Type A KG4PAs represent tumor that was mainly distributed in the posterosuperior and superolateral compartments, type B KG4PAs represent tumor that was mainly distributed in the anteroinferior compartments, and type AB KG4PAs represent tumor that extended into each compartment with characteristics of types 4A and 4B.
RESULTS
The authors identified multiple fibers that anchored the horizontal segment of the internal carotid artery (ICA) to the abducens nerve. The fibers, the sympathetic nerve, and the inferior lateral trunk form a partition-like structure in the LCCS named the abducens nerve-ICA complex (AIC), and the LCCS can be divided into the superolateral and inferolateral compartments by the AIC. Accordingly, the lateral approach was subclassified into the lateral superior (LS) approach and the anterior inferior (AI) approach. The LS approach was mainly used to resect type A KG4PAs, whereas the AI approach was used to resect type B KG4PAs, and a combination of the two was used to resect type AB KG4PAs. The gross-total, subtotal, and partial resection rates were 81.4%, 12.8%, and 5.8%, respectively. The numbers of cases of postoperative transient cranial nerve palsy, postoperative permanent cranial nerve palsy, ICA injury, and CSF leakage were 6 (6.9%), 2 (2.3%), 1 (1.2%), and 1 (1.2%), respectively.
CONCLUSIONS
This study revealed that the LCCS is divided by the AIC into the superolateral and inferolateral compartments, avoiding the misconception that the LCCS has vertical communication. Therefore, the lateral approach was subclassified into the LS approach and the AI approach for the resection of KG4PAs, which allowed a high gross-total resection rate with acceptable safety in the surgical treatment of KG4PAs.
Topics: Humans; Pituitary Neoplasms; Adenoma; Male; Middle Aged; Female; Cavernous Sinus; Cadaver; Adult; Aged; Neuroendoscopy; Natural Orifice Endoscopic Surgery; Nasal Cavity; Young Adult; Neoplasm Grading; Carotid Artery, Internal; Neurosurgical Procedures; Treatment Outcome
PubMed: 38364227
DOI: 10.3171/2023.12.JNS23922 -
Clinical Ophthalmology (Auckland, N.Z.) 2024Although various studies have explored the causes and clinical aspects of cranial nerve palsies, there remains a significant gap in understanding the prognostic factors...
Retrospective Analysis of Factors Related to the Long-Term Recovery of Third, Fourth, and Sixth Cranial Nerve Palsy with Etiologies and Clinical Course in a Tertiary Hospital.
PURPOSE
Although various studies have explored the causes and clinical aspects of cranial nerve palsies, there remains a significant gap in understanding the prognostic factors that influence outcomes. In this study, we sought to address this gap by investigating the incidence, etiologies, clinical courses, and factors associated with long-term recovery, with the aim of enhancing the knowledge base in this field and providing valuable insights for improved patient care.
PATIENTS AND METHODS
This retrospective study evaluated the data gathered from subjects who had third, fourth, and sixth cranial nerve palsy at the ophthalmology outpatient clinic of Phramongkutklao Hospital between April 1, 2012, and April 30, 2022.
RESULTS
Among the three nerves, abducens nerve palsy was the most prevalent finding by most commonly involved. Our study revealed that ischemic and compressive lesions were the most common etiology of oculomotor nerve palsy, comprising 24.6% each. In addition, the most common etiology of trochlear and abducens nerve palsy was trauma, at 31.6% and 27.1%, respectively. Compared with the other nerves, oculomotor nerve palsy was associated with a shorter duration onset of symptoms and recovery period. The best recovery outcomes among the various etiologies were inflammation, ischemic events, and trauma in oculomotor, trochlear, and abducens nerve palsy, respectively. Logistic regression revealed that an onset of <7 days and isolated nerve involvement were significantly associated with good long-term outcomes, with an adjusted odds ratio of 1.73 (95% confidence interval, 1.03-2.89) and 2.56 (95% confidence interval, 1.21-5.39) adjusted for the type of cranial nerve palsy, aged at 50 years, sex, diabetes mellitus, hypertension, dyslipidemia, onset at 7 days, and number of cranial nerves involved, respectively.
CONCLUSION
The onset of symptoms in less than 1 week and isolated nerve involvement were associated with better prognosis in subjects with third, fourth, and sixth cranial nerve palsy.
PubMed: 38352051
DOI: 10.2147/OPTH.S449127 -
Annals of Anatomy = Anatomischer... Apr 2024The purpose of this review is to analyze the origin of ocular motor neurons, define the pattern of innervation of nerve fibers that project to the extraocular eye... (Review)
Review
The purpose of this review is to analyze the origin of ocular motor neurons, define the pattern of innervation of nerve fibers that project to the extraocular eye muscles (EOMs), describe congenital disorders that alter the development of ocular motor neurons, and provide an overview of vestibular pathway inputs to ocular motor nuclei. Six eye muscles are innervated by axons of three ocular motor neurons, the oculomotor (CNIII), trochlear (CNIV), and abducens (CNVI) neurons. Ocular motor neurons (CNIII) originate in the midbrain and innervate the ipsilateral orbit, except for the superior rectus and the levator palpebrae, which are contralaterally innervated. Trochlear motor neurons (CNIV) originate at the midbrain-hindbrain junction and innervate the contralateral superior oblique muscle. Abducens motor neurons (CNVI) originate variously in the hindbrain of rhombomeres r4-6 that innervate the posterior (or lateral) rectus muscle and innervate the retractor bulbi. Genes allow a distinction between special somatic (CNIII, IV) and somatic (CNVI) ocular motor neurons. Development of ocular motor neurons and their axonal projections to the EOMs may be derailed by various genetic causes, resulting in the congenital cranial dysinnervation disorders. The ocular motor neurons innervate EOMs while the vestibular nuclei connect with the midbrain-brainstem motor neurons.
Topics: Animals; Oculomotor Muscles; Motor Neurons; Vertebrates; Orbit; Eyelids; Oculomotor Nerve
PubMed: 38346566
DOI: 10.1016/j.aanat.2024.152225 -
Cureus Jan 2024Wernicke encephalopathy (WE) is a rare but life-threatening syndrome that is commonly associated with chronic alcoholism. It has also been found to be associated with...
Wernicke encephalopathy (WE) is a rare but life-threatening syndrome that is commonly associated with chronic alcoholism. It has also been found to be associated with malnutrition, prolonged parenteral nutrition, hemodialysis, hyperemesis gravidarum, gastroplasty, and AIDS. It usually presents as a clinical triad of confusion, ophthalmoplegia, and gait ataxia. Nystagmus is usually the most common and earliest ophthalmologic sign. We report a case of non-alcoholic WE in a patient who had prior bariatric surgery and was treated for malnutrition and sepsis, with nystagmus being the initial presentation. The MRI of the brain was normal. The diagnosis of WE was made clinically and was supported by the patient's symptomatic and clinical recovery following intravenous thiamine treatment. It is essential to highlight that a high level of suspicion is needed to diagnose non-alcoholic WE to allow the commencement of appropriate treatment and reduce morbidity and mortality rates related to this condition.
PubMed: 38344547
DOI: 10.7759/cureus.52121 -
Cureus Jan 2024Otitis media, a common inflammation of the middle ear, frequently complicates upper respiratory infections. Gradenigo's syndrome, a rare complication, manifests as...
Otitis media, a common inflammation of the middle ear, frequently complicates upper respiratory infections. Gradenigo's syndrome, a rare complication, manifests as suppurative otitis media, abducens nerve palsy, and severe trigeminal nerve pain. Prompt recognition is vital because of the proximity of the infection to critical neurovascular structures. We present the case of a 38-year-old female who presented with facial pain, otalgia, and diplopia following an upper respiratory infection. Examination revealed facial weakness and abducens nerve palsy. Laboratory results showed elevated inflammatory markers. Imaging confirmed middle ear involvement. Antibiotics were initiated, and myringotomy was performed, resulting in a successful outcome. This case report contributes to understanding Gradenigo's syndrome's clinical nuances, emphasizing the necessity of a structured diagnostic and therapeutic approach. Ongoing research is crucial for refining diagnostic criteria, optimizing treatment, and enhancing pathophysiological understanding. Increased medical education is imperative to ensure early detection and improved patient outcomes.
PubMed: 38327941
DOI: 10.7759/cureus.51865 -
The American Journal of Case Reports Feb 2024BACKGROUND With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more...
BACKGROUND With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more uncommon is Gradenigo syndrome (GS), a result of PA, characterized by a triad of otitis media or purulent otorrhea, pain within the regions innervated by the first and second division of the trigeminal nerve, and ipsilateral abducens nerve palsy. Recent literature has demonstrated increasing reports of Fusobacterium necrophorum isolated in cases of GS. CASE REPORT A 21-year-old man presented with otalgia, reduced hearing, and severe headache. Examination revealed right-sided purulent otorrhea, anesthesia within the trigeminal nerve distribution, and an ipsilateral abducens nerve palsy. F. necrophorum was isolated from an ear swab and a blood culture. Computed tomography and magnetic resonance imaging (MRI) demonstrated otomastoiditis, PA, cavernous sinus thrombosis, and severe stenosis of the petrous internal carotid artery. He was treated with intravenous benzylpenicillin, underwent a mastoidectomy and insertion of a ventilation tube, and was started on a 3-month course of dabigatran. Interval MRI showed improved internal carotid artery caliber, persistent petrous apex inflammation, and normal appearance of both cavernous sinuses. Follow-up clinical review noted persistent abducens and trigeminal nerve dysfunction. CONCLUSIONS We identified 190 cases of PA; of these, 80 presented with the classic Gradenigo triad. Fusobacterium sp. were cultured in 10% of GS cases, making them the most frequent isolates. Due to the fastidious nature of F. necrophorum, it may be underrepresented in the historical literature, and we recommend that empiric antibiotics cover anaerobic organisms.
Topics: Male; Humans; Young Adult; Adult; Petrositis; Fusobacterium necrophorum; Otitis Media; Abducens Nerve Diseases; Inflammation; Anti-Bacterial Agents
PubMed: 38319911
DOI: 10.12659/AJCR.942652 -
Cureus Jan 2024This case report details the occurrence of bilateral sequential abducens nerve palsy in a previously healthy 42-year-old woman two days after receiving her first dose of...
This case report details the occurrence of bilateral sequential abducens nerve palsy in a previously healthy 42-year-old woman two days after receiving her first dose of the Pfizer-BioNTech COVID-19 vaccine (BNT162b2). Despite the widespread global administration of COVID-19 vaccines, instances of abducens palsy following vaccination are limited in the available literature. Considering the temporal association between vaccination and symptom onset, the absence of underlying medical conditions predisposing to such neurological manifestations, normal brain imaging results, the occurrence of other cranial palsies post-vaccination, and analogous occurrences after different vaccinations, we propose a plausible connection between the patient's abducens palsy and the COVID-19 vaccination. Our findings contribute to the growing body of evidence regarding the side effects and safety profile of COVID-19 vaccines. Importantly, the resolution of symptoms with conservative management and the uneventful administration of the second vaccine dose suggest that the observed abducens palsy may be a transient and isolated reaction.
PubMed: 38313970
DOI: 10.7759/cureus.51682