Isolated Abducens Nerve Palsy due to Focal Patchy Inflammatory Lesion and review of the literature.

Sangle R P,Nivargi V, Dixit P

Sangle R P,Nivargi V, Dixit P

Abstract

Background: Convergent squint due to ‘isolated abducens nerve palsy’ (IANP) in otherwise normal patients is not often seen. Reports on natural history related to causes, time of improvement and recurrences is varied and perplexing. Objective 1) to relate IANP to the ‘focal patchy inflammatory dural lesion’ (FPIDL) along the lateral wall of cavernous sinus using magnetic resonance imaging (MRI), 2) to assess the use of anti-inflammatory drugs and steroids, 3) understanding incidence of recovery and recurrences . Patient & method: Retrospective review of seven patients of IANP with MRI neuroimaging and steroidal therapy. Cerebrospinal fluid (CSF) was investigated in four patients only. Results: MRI showed FPIDL affecting lateral wall of cavernous sinus all along the abducens nerve tract. Recurrent palsy similar independent lesion. Both treated with anti-inflammatory and steroidal drug therapy. Follow-up MRIs within two weeks of therapy shows significant recovery with regression of FPIL. Conclusion: Skull base MRI differentiates FPIDL from intra-nuclear and other structural causes. IANP recurrences appear independent, have similar lesions and also respond to anti-inflammatory and steroidal therapy. The authors suggest MRI-skull base neuroimaging and reviews IANP.

References

1. Lee JH, Lee HK, Park JK, Choi CG,Suh DC: Cavernous sinus syndrome: clinical features and differential diagnosis with MR imaging. AJR Am J Roentgenol. 2003, 181 (2): 583-590.
2. Moster ML, Savino PJ, Sergott RC, Bosley TM, Schatz NJ. Isolated sixth nerve palsies in younger adults. Arch Ophthalmol. 1984; 102:1328–1330
3. Tamhankar MA, Biousse V, Ying GS, et al. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology. 2013; 120(11):2264–2269.
4. Richards BW, Jones FR, Jr, Younge BR. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves.Am J Ophthalmol. 1992; 113(5):489–496.
5. Yousuf SJ, Khan AO; .Presenting features suggestive for later recurrence of idiopathic sixth nerve paresis in children. J AAPOS. 2007; 11(5):452–455. [PubMed]
6. Anthony J King1, Emma Stacey2, Gail Stephenson3 and Roger B Trimble4 Spontaneous recovery rates for unilateral sixth nerve palsies; Eye (1995) 9, 476–478; doi: 10.1038/eye.1995.110
7. Jacobson DM, McCanna TD, Layde PM. Risk factors for ischemic ocular motor nerve palsies. Arch Ophthalmol. 1994; 112:961–966
8. Asbury AK, Aldredge H, Hershberg R, Fisher CM. Oculomotor palsy in diabetes mellitus: a clinico- pathological study. Brain. 1970; 93:555–566
9. Meltzer CC1, Fukui MB, Kanal E, Smirniotopoulos JG; MR imaging of the meninges. Part I. Normal anatomic features and nonneoplastic disease; Radiology. 1996 Nov; 201(2):297-30
10. Patel SJ, Lundy DC. Ocular manifestations of autoimmune disease. Am Fam Physician. 2002 Sep 15. 66(6):991-8. [Medline]
11. Mohsen Azarmina, MD1 and Hossein Azarmina, MD2; J Ophthalmic Vis Res. 2013 Apr; 8(2): 160-171. PMCID: PMC3740468 The Six Syndromes of the Sixth Cranial Nerve.
12. Kurbanyan K, Lessell S. Intracranial hypotension and abducens palsy following upper spinal manipulation. Br J Ophthalmol. 2008;92:153–155. [PubMed]
13. Kuhl V, Andreas J, Müller-Forell W, Thömke F, Hopf HC. Spontaneous intracranial hypotension syndrome in cervicothorackc cerebrospinal fluid leak. Nuklearmedizin. 2000;
39:N22–24. [PubMed]
14. Krishna R, Kosmorsky GS, Wright KW.Pseudotumor cerebri sine papilledema with unilateral sixth nerve palsy. J Neuroophthalmol. 1998;18:53–55. [PubMed]
15. Michael S Lee, MD, Steven L Galetta, MD, and Nicholas J Volpe, MD, Grant T Liu, MD correspondence: Sixth nerve palsies in children. Pediatric Neurology; January 1999Volume 20, Issue 1, Pages 49–52 ;
16. Sakalas R, Harbison JW, Vines FS, Becker DP. Chronic sixth nerve palsy. An initial sign of basisphenoid tumors. Arch Ophthalmol. 1975; 93:186–190. [PubMed]
17. King AJ1, Stacey E, Stephenson G, Trimble RB. Spontaneous recovery rates for unilateral sixth nerve palsies. Eye (Lond). 1995; 9 (Pt 4):476-8.
18. Schatz NJ, Farmer P. Tolosa- Hunt syndrome: the pathology of painful ophthalmoplegia. In: Smith JL, editor. Neuroophthalmology. St. Louis: C.V. Mosby; 1972.
19. Campbell RJ, Okazaki H. Painful ophthalmoplegia (Tolosa- Hunt variant): autopsy findings in a patient with necrotizing intracavernous carotid vasculitis and inflammatory disease of the orbit. Mayo Clin Proc.1987; 62:520–526. [PubMed]
20. Steven R. Hamilton, M.D., Simmons Lessell, M.D. Recurrent Idiopathic Lateral Rectus Muscle Palsy in Adults: American Journal of Ophthalmology, Volume 112, Issue 5, November 1991, Pages 540-542
21. Ebright JR, Pace MT, Niazi AF.Septic thrombosis of the cavernous sinuses. Arch Intern Med. 2001; 161:2671–6. [PubMed]