This is sometimes due to injury of the sixth cranial nerve during labor or delivery. Thrombosis of the cerebral veins and sinuses is an infrequent cerebrovascular disorder. Late onset of abducens palsy after le fort i maxillary osteotomy. This article describes three incidents when inadvertent abducens nerve palsy secondary to a dental local anaesthetic occurred during removal an upper wisdom tooth, resulting in paresis of the lateral rectus muscle and diplopia. Sixth nerve palsy abducens nerve palsy lateral rectus palsy hypertension. Oct 16, 2015 sixth nerve palsy may be caused by many things, including stroke, brain aneurysm, diabetic neuropathy, trauma, infections, inflammation, tumors, migraine headaches or intracranial pressure. The abducens nerve leaves the brainstem at the junction of the pons and the medulla, medial to the facial nerve. It runs upward between the pons and the clivus, and then pierces the dura mater to run between the dura and the skull through dorellos canal. Aug 07, 20 age cranial nerve vi palsy can occur in all age groups. Sixth nerve palsy, or abducens nerve palsy, is a disorder associated with dysfunction of cranial nerve vi the abducens nerve, which is responsible for causing contraction of the lateral rectus muscle to abduct i. Abducens nerve palsy is the most commonly affected of the ocular motor nerves. Eventually, the correct diagnosis was established with cerebral mr imaging. Abducens nerve palsy is uncommon following traumatic brain injury, with an incidence of 1% to 2.
The affected eye turns in toward the nose and is unable to abduct properly. Finally, following input from opthalmology colleagues, recommendations for appropriate management are made to ensure a good outcome. Abducens nerve palsy as initial presentation of multiple. Sixth cranial nerve palsy affects the lateral rectus muscle, impairing eye abduction. The internal carotid artery is located medially in the cavernous sinus, and the pituitary. It is the most common ocular cranial nerve palsy to occur in isolation 1. Abducens nerve paralysis, botilinum toxin, diplopia. It has a purely somatic motor function providing innervation to the lateral rectus muscle. Aan members 800 8791960 or 612 9286000 international nonaan member subscribers 800 6383030 or 301 2232300 option 3, select 1 international. Sixth cranial nerve abducens nerve palsy brain, spinal. The oculomotor nerve cn iii, trochlear nerve cn iv, and abducens nerve cn vi. The cisternal portion of the left abducens nerve is smaller than the right, but appears intact. This is especially true when the abducens nerve is affected in isolation, since in the current era of cost. Management of sixth nerve palsy different approaches.
A sixth nerve palsy, also known as abducens nerve palsy, is a neurological defect resulting from an impaired sixth nerve or the nucleus that controls it. Apr 07, 2017 sixth cranial nerve dysfunction in children the significance of sixth cranial nerve dysfunction, and how to catch it in time for management to be successful. Intracranial hypotension and abducens palsy following upper spinal manipulation. An overview of the abducens nerve, including its course, the role it plays in eye movements and abducens nerve palsy. We present a case with recurrent orbital myositis sequentially affecting both lateral rectus muscles separately. A 16yearold girl with altered mental status, abducens. The abducens sixth cranial nerve controls the lateral rectus muscle, which abducts the eye. Pdf benign recurrent abducens sixth nerve palsy fatih. The lesion is in the expected region of the left abducens nucleus. Isolated abducens nerve palsy in a patient with scrub typhus. Acquired isolated abducens nerve palsy in infants and children is a rare condition.
Vi nerve palsy abducens palsy paralisia do vi nervo abducente renato luiz nahoum curi. No associated contrast enhancement, diffusion restriction or expansion. In this article, we shall look at the anatomy of the abducens nerve its anatomical course, motor functions and clinical relevance. A more recent multicenter prospective study assessed the diagnostic yield of neuroimaging in 109 patients presenting with acute third, fourth or sixth nerve palsy and found the overall yield of neuroimaging to be 16. Diagnosis is determined retrospectively after exclusion of the main conditions of sixth nerve palsy in childhood, and is different from benign recurrent forms. Abducens nerve palsy is a common clinical finding in neurology practice. Jun 15, 2016 abducens nerve palsy is a common clinical finding in neurology practice.
Clinical examination a comprehensive collection of clinical examination osce guides that include stepbystep images of key steps, video demonstrations and pdf mark schemes. A wide variety of abnormalities, both primary to the nerve itself and secondarily involving the nerve, can paralyze the abducens nerve. To describe the causes and treatment of sixth abducens nerve palsy in a series of pediatric patients. Transposition procedures performed for sixth nerve palsy yield the best outcomes because only one muscle is affected. Spontaneous recovery rates for unilateral sixth nerve. The injury of the abducens nerve can occur anywhere along its long course, so.
Abducens nerve palsy as a focal neurological deficit is a rare clinical manifestation in these patients. Sixth nerve palsy genetic and rare diseases information. A 47yearold woman presented with six episodes of horizontal binocular double vision over a 2year period. Management of sixth nerve palsy different approaches romanian. Abducens nerve palsy as initial presentation of multiple myeloma and intracranial plasmacytoma elochukwu ibekwe 1, neil b. The patients were reassured and managed conservatively and there were no long. The abducens nerve is the sixth paired cranial nerve. This was a 14year retrospective study of sixth nerve palsy in children under 14 years of age. This is also known as lateral rectus palsy and abducens nerve palsy. This article presents a simple clinical approach to sixth nerve palsy based on the anatomy of the abducens nerve and will conclude with recommendations for. Abducens nerve palsy sixth cranial nerve palsy clinical. Ct imaging was significant for extensive dural calcification in the spine and calcification of the skull base, likely involving dorellos canal. General features sixth nerve palsy paresis is defined as the abolition or reduction, unilateral or bilateral, of oculomotor sixth nerve function, which innervates lateral rectus muscle, resulting in neuro muscular.
Abducens nerve palsy is the most common ocular motor paralysis. Recurrent abducens nerve palsy and hypophosphatasia. The abducens nerve, the sixth cranial nerve, innervates the lateral rectus muscle of the eye and is responsible for lateral horizontal ocular movement. Age cranial nerve vi palsy can occur in all age groups. Consumer version the trusted provider of medical information since 1899. In the first episode, the absence of the required symptoms for the diagnosis of orbital myositis led to the erroneous diagnosis of sixth nerve palsy. Pdf isolated abducens nerve palsy in a patient with. Unilateral abducens nerve palsy following perinatal stroke of. Abducens nerve palsy sixth cranial nerve palsy treatment. The abducens nerve floats freely within the cavernous sinus.
Recurrent nerve palsy may possibly be induced by mechanical compression of the sixth cranial nerve in dorellos canal from calcification due to hypophosphatasia syndrome. Aug 08, 2000 causes of isolated abducens nerve palsy include aneurysms of the vertebral artery va, tumor, diabetes mellitus, and meningitis. The condition can be congenital and affect a person from birth. The inability of an eye to turn outward and results in a convergent strabismus or esotropia of which the.
This may result in horizontal double vision diplopia with in turning of the eye and decreased lateral movement. Isolated sixth cranial abducens nerve disorder is a rare condition associated with gestation, and very few cases have been reported see table 1. Sixth nerve palsy results from dysfunction or damage of your sixth cranial nerve, also known as the abducens nerve. Biochemical testing revealed a persistently low alkaline phosphatase level. Five cases of abducens nerve palsy happened during pregnancy 26, four cases happened postpartum 1,79 and one case was in second trimester also, two cases did not have high blood. The underlying pathophysiological mechanism is unknown. Benign recurrent sixth abducens nerve palsies in children. Jan 01, 2009 benign recurrent abducens nerve palsy is a rare clinical entity, but it should be included in the differential diagnosis of sixth nerve palsy in the absence of obvious underlying pathology. Mr imaging offers the best opportunity to detect the underlying abnormality causing abducens nerve palsy. We describe a patient with isolated right abducens nerve palsy due to vascular compression of the elongated left va.
We report a 26 year old patient presented at 38 weeks gestation with abducens nerve palsy. Patients with abducens nerve palsy are unable to move the affected eye laterally in order to avoid diplopia, patients will turn their heads away from the lesion so that both eyes are looking sideways check deep tendon reflexes and strength to exclude corticospinal tract involvement. Recurrent orbital myositis mimicking sixth nerve palsy. Though neurological sequelae including mononeuropathy, encephalopathy, transverse myelitis, polyradiculopathy, guillainbarre syndrome, optic neuropathy and oculomotor neuropathy have been reported in medical literature, the abducens nerve despite its notoriety in cranial. Therefore, sixth nerve palsy is most common oculomotor nerve palsies, representing up to 40% of these. A 16yearold girl with altered mental status, abducens nerve. It runs upwards and forwards from this position to reach the eye. Images in clinical medicine from the new england journal of medicine traumatic abducens nerve palsy. The inability of an eye to turn outward and results in a convergent strabismus or esotropia of which the primary symptom is diplopia commonly known as double. Apr 04, 2017 the purpose of the study is to testify whether ocular electroacupuncture or ocular acupuncture is effective for abducens nerve palsy anp, through treating anp patient for 6 weeks, using selfinvented acupoints according to anatomy of extraocular muscles innervated by abducens nerve, and using sham acupuncture as controlled group, and try to. The eye may be slightly adducted when the patient looks straight ahead. Botilinum injection can help patients with sixth nerve palsy during the recovery period. In many instances, the origin is obvious and management straightforward. Review of a series with abducens nerve palsy turkish neurosurgery.
Effects of ocular electroacupuncture on abducens nerve palsy. Double augmented vertical rectus transposition for large. Results benign sixth nerve palsy subgroup with or without recurrence of 253 children identified with sixth nerve palsy, 225 had only sixth nerve involvement. Horsley 1, lan jiang 1, nadinestella achenjang 1, azubuogu anudu 1, zeeshan akhtar 1, karina g. The abducens nerve cn vi course motor teachmeanatomy. The sixth cranial nerve sends signals to your lateral rectus muscle. Ovoid t2 hyperintense lesion in the posterior aspect of the pons just to the left of midline measuring 3 mm. Creutzfeldtjakob disease cjd is a rare neurodegenerative disorder with characteristic clinical and diagnostic features. The incidence of unilateral abducent nerve palsy from head injury has been reported to occur in 1% 2. Eye patches, glasses, corticosteroids, andor botulinum toxin may be used to ease symptoms.
The injury of the abducens nerve can occur anywhere along its long. Causes of isolated abducens nerve palsy include aneurysms of the vertebral artery va, tumor, diabetes mellitus, and meningitis. The palsy may be secondary to nerve infarction, wernicke encephalopathy, trauma, infection, or increased intracranial pressure, or it may be idiopathic. Recurrent abducens nerve palsy and hypophosphatasia syndrome. Sixth nerve palsies have no predilection for males or females abducent nerve paralysisabducent nerve paralysis 8. Vascular compression of the nerve is suspected but never demonstrated. The abducens nucleus is located in the pons, on the floor of the fourth ventricle, at the level of the facial colliculus. Aan members must change their passwords on the aan site. Benign recurrent abducens nerve palsy is a rare clinical entity, but it should be included in the differential diagnosis of sixth nerve palsy in the absence of obvious underlying pathology. Creutzfeldtjakob disease presenting with abducens nerve palsy. Because the highly variable symptoms, recent neuroimaging plays a key role in the diagnosis.
Though neurological sequelae including mononeuropathy, encephalopathy, transverse myelitis, polyradiculopathy, guillainbarre syndrome, optic neuropathy and oculomotor neuropathy have been reported in medical literature, the abducens nerve despite its. We describe the unusual case of an elderly man who presented to our ophthalmology clinic with horizontal diplopia secondary to an abducens nerve cranial nerve six palsy and was subsequently diagnosed with cjd. Pdf abducens nerve palsy anp is the most common isolated palsy. Abducens nerve palsy in spontaneous intracranial hypotension. From 1968 to 2015, only 9 cases have been reported in the literature. The anatomical course of the abducens nerve from its origin to the lateral rectus muscle are discussed as well as potential mechanisms for the dental local anaesthetic to impact upon the nerve. Sixth cranial abducens nerve palsy neurologic disorders. Abducens nerve palsy during pregnancy is an extremely rare condition and therefore the clinical course during pregnancy has not been fully explored. He was admitted to the university of iowa hospitals and clinics for decreasing level of. The nerve enters the subarachnoid space when it emerges from the brainstem. Management of acute cranial nerve 3, 4 and 6 palsies. Cranial nerve vi innervates the lateral rectus muscle.
Dengue fever is an endemic illness in the tropics with early and post infectious complications affecting multiple systems. Axons from the facial nerve loop around the abducens nucleus, creating a slight bulge the facial colliculus that is visible on the dorsal surface of the floor of the fourth ventricle. We present two cases with sudden onset of diplopia and headache. Fig 1 schematic of the anatomical course of the abducens. The patients history, examination, and diagnostic tests were consistent with abducens nerve palsy. We describe an adult patient with, altogether, 11 periods of unilateral rightsided abducens palsy and arterial contact at the root exit zone of. A sixth cranial nerve palsy most commonly arises from an acquired lesion occurring anywhere along its path between the sixth nucleus in the dorsal pons and the lateral rectus muscle within the orbit.
This 44yearold male with a history of hypertension awoke with the worst headache of his life. Causes and prognosis in 4278 cases of paralysis of the oculomotor, trochlear and abducens cranial nerves. The sixth cranial nerve, or abducens nerve, is the most commonly affected cranial nerve in children presenting with acquired strabismus. Benign isolated abducens nerve palsy is a rare clinical entity characterized by spontaneous resolution within 6 months. Recurrent nerve palsy may possibly be induced by mechanical. Cranial nerve vi abducens nerve innervates the lateral rectus muscle. Pdf isolated nontraumatic abducens nerve palsy researchgate. Abducens nerve palsy causes an esotropia due to the unopposed action of the antagonistic medial rectus muscle. Sixth nerve palsy may be caused by many things, including stroke, brain aneurysm, diabetic neuropathy, trauma, infections, inflammation, tumors, migraine headaches or intracranial pressure. About 10% of patients with abducent nerve palsy have bilateral paralysis, which is conventionally accompanied by further intracranial, skull, and cervical spine injuries 5. Dec 01, 2016 whereas abducens nerve palsy during pregnancy is an extremely rare condition, we report here a 40yearold patient with diplopia, blurring of vision and abducens nerve palsy in the 39 th week of pregnancy with history of hypertension htn. Patients with abducens nerve palsy were noted to have a.