Pontine tuberculoma presenting with horizontal gaze palsy

A 38-year-old immunocompetent man presented with a horizontal supranuclear gaze palsy as the only neurologic manifestation of a pontine tuberculoma. Although a biopsy of the brain lesion was not performed, it was attributed to tuberculosis because of chest x-ray evidence. The patient was given empirical anti-tuberculous therapy. After one month, the gaze palsy had fully recovered and repeat MRI showed a decrease in the size of the lesion. This is the first reported case of supranuclear gaze palsy without diplopia as a manifestation of a tuberculous brain stem lesion.

Alveolar rhabdomyosarcoma of the clivus with intrasellar expansion: Case report

Rhabdomyosarcomas are common tumors of the head and neck region in children. However, a primarily intracranial localization of this tumor entity is rare. We report on a 3-year-old boy presenting with double vision due to left VI (th) nerve palsy. No other neurological deficits were recognized by clinical inspection. MRI scans visualized an enhancing mass lesion in the upper clivus compressing the cavernous sinus and the pituitary gland. Transsphenoidal biopsy was performed and histopathological examination as well as molecular diagnostics confirmed the diagnosis of an alveolar rhabdomyosarcoma (ARMS). Staging identified a metastatic lesion in the fourth thoracic vertebra resulting in the diagnosis of stage IV disease. Treatment modality included stereotactic radio- and chemotherapy.

Ocular neuromyotonia with spastic lid closure

Ocular neuromyotonia is characterized by tonic spasms of extraocular muscles evoked by eccentric gaze that induces transient strabismus and diplopia. We report the case of a 70-year-old woman who initially presented with unilateral deficits in fifth and sixth cranial nerve functions attributed to a fifth cranial nerve schwannoma. After radiation treatment, she developed neuromyotonia and synkinesis of the ipsilateral third cranial nerve. During the attacks of neuromyotonia, the left eyelids were often spastically closed, a phenomenon not previously reported. The ocular neuromyotonia regressed spontaneously within 3 years, but components of the synkinesis persisted. Ephaptic transmission in a damaged third cranial nerve may be responsible for the neuromyotonia and synkinesis. Synkinesis is a more enduring manifestation.

Optic neuropathy and sixth cranial nerve palsy caused by compression from a dolichoectatic basilar artery

A 53-year-old man with progressive visual loss in the right eye and diplopia manifested dysfunction of the right optic nerve and the right sixth cranial nerve. MRI revealed a markedly enlarged and tortuous basilar artery, its proximal portion compressing the right sixth cranial nerve at the exit from the pons and its distal portion elevating and compressing the right optic nerve. This is the first report of optic neuropathy and sixth cranial nerve palsy caused by a dolichoectatic basilar artery.

A Case of Bilateral Simultaneous Sixth Cranial Nerve Palsies Secondary to Diabetes Mellitus

Ocular motor cranial nerve palsy secondary to diabetes mellitus usually affects one cranial nerve at a time. We report a patient with simultaneous bilateral sixth nerve palsies attributed to diabetes. Although an extremely rare cause of this phenomenon, diabetes may be the explanation after other causes have been excluded.

Posttraumatic acute bilateral abducens nerve palsy in a child

INTRODUCTION

Acute bilateral abducens nerve palsy after traumatic clivus epidural haematoma is a rare condition in trauma patients.

CASE REPORT

In this report, we present a case with this rare neurological complication of head trauma and discuss the possible mechanisms for abducens nerve palsy and clival epidural haematoma.

[Case of herpes zoster ophthalmicus with abducent palsy: the cause and magnetic resonance imaging findings]

PURPOSE

To report the cause and magnetic resonance imaging (MRI) findings in a case of abducent palsy following herpes zoster ophthalmicus.

CASE

A 76-year-old man presented with acute onset of pain, a vesicular cutaneous eruption and herpes zoster ophthalmicus on the right side. He developed complete abducent palsy on the right side two weeks after onset. MRI with gadolinium enhancement showed Meckel's sinus, which contains the trigeminal ganglion, and the abducent nerve on the right side. The patient was treated with intravenous acyclovir and methylprednisolone. The abnormal enhancement shown on MRI vanished immediately and the ophthalmoplegia resolved significantly.

CONCLUSION

This is the first reported case where an affected cranial nerve was detected next to the inflammatory cavernous sinus in ophthalmoplegia following herpes zoster ophthalmicus. These MRI findings showed that this ophthlamoplegia was induced by direct viral invasion or extension of inflammation to the ipsilateral cranial nerve. Further studies need to be performed to clarify the role of specific antiviral therapy or anti-inflammatory agents in treating this complication of herpes zoster.

Paralysies oculomotrices douloureuses : une approche diagnostique

We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.

Bilateral abducent and facial nerve palsies following fourth ventricle shunting: two case reports

CASE REPORTS

Treatment of isolated fourth ventricle syndrome is difficult and there is no widely agreed method. Fourth ventriculo-peritoneal shunting is the most commonly utilized procedure for the management of this syndrome. Complications from shunting are common and are usually related to malfunction, infection, dislocation and overdrainage. We present two unusual cases in which both patients developed bilateral abducens and facial nerve palsies following shunting of an isolated fourth ventricle. Magnetic resonance imaging (MRI) in both cases revealed collapse of the fourth ventricles with downward displacement of the brain stem. In the first case the trans-tentorial pressure difference was equilibrated with the aid of a "Y" connector between the supratentorial and infratentorial shunts, with full recovery of the neurological deficits; in the second case this approach failed and following a complicated neurosurgical course successful endoscopic aqueductal stenting was performed.

DISCUSSION

Pathogenesis of cranial nerve palsies following fourth ventricle shunting and the rationale of treatment are discussed and the literature is reviewed.

Intracranial peripheral primitive neuroectodermal tumor manifesting as abducens nerve palsy

INTRODUCTION

Peripheral primitive neuroectodermal tumor (PNET) occurring as an extra-axial lesion within the intracranial space and extending to the subarachnoid space is extremely rare.

CASE REPORT

An 18-month-old girl presented with an intracranial peripheral PNET manifesting as abducens nerve palsy. Magnetic resonance imaging on admission revealed a lesion affecting the trigeminal and abducens nerves. The tumor was partially removed via the subtemporal approach. Histological examination showed a high-grade, undifferentiated neoplasm of small cell type with positive immunostaining for MIC2. The histological diagnosis was peripheral PNET.

OUTCOME

Craniospinal radiotherapy reduced the tumor size, but adjuvant chemotherapy designed for Ewing's sarcomas and PNETs was not effective. She died 1 month after the last chemotherapy, despite whole craniospinal irradiation (total dose 53.2 Gy) and chemotherapy.

Usefulness of MR imaging in children without characteristic clinical findings of Duane's retraction syndrome

BACKGROUND AND PURPOSE

Duane's retraction syndrome (DRS) consists of a congenital abduction deficit of the eyeball accompanied by retraction of the globe on attempted adduction and by upshoots or downshoots of the affected eye on adduction. These characteristic diagnostic signs of DRS, however, might not be manifested in early childhood. We evaluated the usefulness of MR imaging as a diagnostic tool in such cases.

METHODS

Thin-section gradient-echo imaging at the brain stem level was performed in two pediatric patients with only abduction deficit and 10 control children. Imaging findings were analyzed focused on the presence or absence of the abducens nerve.

RESULTS

The abducens nerve on the affected side was absent in three of three affected eyes in two patients. The right and left abducens nerves were well identified in all 10 control subjects.

CONCLUSION

MR imaging is useful for the differential diagnosis of abduction deficit of the eyeball in pediatric patients. The absence of the abducens nerve suggests DRS strongly in children with abduction deficit.

Aspergillus granuloma of the cavernous sinus: magnetic resonance imaging with pathologic correlation

This case illustrates the correlation between Magnetic Resonance Imaging (MRI) and the pathological findings in a case of cavernous sinus (CS) aspergilloma.

Primary Cerebral Angiitis Containing Marked Xanthoma Cells With Massive Intraparenchymal Involvement-Case Report-

A 27-year-old woman was referred to our hospital with mild disorientation, bilateral abducens nerve palsy, and mild left hemiparesis. Magnetic resonance (MR) imaging revealed diffuse mass lesions resembling malignant glioma in the right frontal intraparenchymal region, with enhancement of multiple meningeal and intraparenchymal nodules. Partial resection of the frontal lesion was performed. Histological examination revealed that the specimens consisted of brain tissue, with marked perivascular infiltration of histiocytes and sheets of xanthomatous cells. The diagnosis was primary cerebral angiitis containing marked xanthoma cells. Steroid therapy was administered over 1 week. MR imaging showed that the remaining lesions resolved gradually, and had disappeared 2 years after surgery. No neurological symptoms or recurrence of the tumor has been observed during the 6-year period since the operation.

Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment

The role for immediate neuroimaging in patients 50 years of age or older with acute isolated third, fourth, and sixth nerve palsies is controversial. We prospectively evaluated 66 patients, aged 50 years and older (median 67 years, range 50-85), with acute isolated ocular motor mononeuropathies. Our purpose was to evaluate both the role of neuroimaging and the role of clinical assessment in determining etiology. We found that clinical features, including time to maximal diplopic symptoms, were not predictive of etiology (median 2 days to maximal diplopic symptoms for both peripheral microvascular and other etiologies). The presence of any common vascular risk factor, including diabetes mellitus, hypertension, hypercholesterolemia, or coronary artery disease, was significantly associated with peripheral microvascular etiology in this cohort (p=0.0004, Fisher's exact test). Despite the high prevalence of peripheral microvascular ischemia as an etiology in this age group, other causes were identified by magnetic resonance imaging (MRI) or computed tomography (CT) scanning in 14% of patients. Diagnoses included brainstem and skull base neoplasms, brainstem infarcts, aneurysms, demyelinating disease, and pituitary apoplexy. Neuroimaging procedures may have a role in the initial evaluation of patients 50 years of age or older with acute ocular motor mononeuropathies.

Schwannoma of the abducens nerve in the cavernous sinus

Six cases of cavernous abducens nerve schwannoma have been reported. A new case of a 39 year old female with abducens nerve paresis, exophtalmos, chemosis and headache due to a 1,36 x 2,58 cm cystic right cavernous abducens nerve schwannoma is presented and discussed. The cavernous sinus was opened between the trochlear and ophthalmic nerves. A portion of the tumor capsule adherent to the internal carotid artery was not resected. No deficits were added by surgery. After 30 months of follow up there is no evidence of relapse and only abducens nerve paresis persists.

The mechanism of injury of the abducens nerve in severe head trauma: a postmortem study

The aim of this study is to investigate the mechanism of injury of abducens nerve at petroclival region in severe head trauma. Twenty specimens provided from 10 autopsied cases due to severe head trauma were investigated macroscopically and histopathogically. The slices of the abducens nerve taken consecutively along its course at petroclival region were stained with Hematoxylline-Eosin and evaluated under light microscope. In addition, coexisting cervical injuries in these cases were assessed macroscopically. Edema and perineural hemorrhagia of abducens nerve were identified in all cases. Nerve injury was found more exaggerated at the sites of dural entry point and petrous apex than any other parts of the abducens nerve. Furthermore, microscopically, also remarkable perineural hemorrhage of the abducens nerve was observed at the site of its anastomoses with the sympathetic plexus on the lateral wall of the internal carotid artery (ICA). Abducens nerve is injured at the sites of dural entry point, petrous apex and lateral wall of the ICA, directly proportional with the severity of the trauma. This finding is also significant in verification of the severe head trauma.

Sixth nerve schwannoma: a case report with literature review

A 40-year-old woman presented with diplopia and left VI nerve palsy. After investigations, diagnosis of a meningioma in the parasellar-prepontine region was considered. Following angiography and embolization, near-total excision of the tumour attached to abducens nerve was performed. Histological examination was consistent with the diagnosis of schwannoma. This is the thirteenth case report of a schwannoma of cranial nerve VI and the first such case where embolization of feeding tumour vessels was performed.

Horizontal monocular saccadic failure: an unusual clinically isolated syndrome progressing to multiple sclerosis

This paper describes an unusual clinically isolated syndrome of inflammatory demyelination that was characterized by a right VI nerve palsy and right internuclear ophthalmoparesis (INO), along with an unusual form of dissociated nystagmus. Magnetic resonance imaging (MRI) revealed an isolated lesion within the right dorsomediolateral pontine tegmentum. Four years later, the subject developed a partial sensory transverse myelitis, confirming clinically definite multiple sclerosis (MS). This paper extends the range of isolated syndromes associated with MS.