Delayed Diplopia After Sports-Related Concussion: A Multidisciplinary Approach to Evaluation and Management

ObjectiveTo highlight a multidisciplinary approach to the diagnosis and management of unilateral abducens palsy after a sports-related concussion.BackgroundMild traumatic brain injury (TBI) often leads to disruptions in visual functioning, affecting convergence, saccades, smooth pursuit, and accommodation. More severe TBI injuries may result in structural injuries to the ocular muscles, nerves, or the brain itself.Design/MethodsNA.ResultsCase: We present the case of a 33-year-old male with unilateral abducens nerve palsy after a sports-related concussion with loss of consciousness and multiple hemorrhagic contusions. The patient's visual symptoms manifested several days after the injury. With a multi-disciplinary evaluation involving specialists representing neurosurgery, endovascular neurology and neuro-ophthamology, unenhanced magnetic resonance imaging revealed multiple foci of intraparenchymal microhemorrhages and siderosis consistent with diffuse axonal injury (DAI), and an incidental parasagittal cavernoma. The delayed development of a sixth nerve palsy raised our suspicion for secondary axotomy, as has been described following TBI. While the probability of recovery is high, close follow up is imperative to address evolution of the patient's symptoms. In this case, the patient developed imbalance and headaches in association with his visual symptoms. For the imbalance we use physical therapy with therapists trained in vestibular therapy and for the visual symptoms we use vision therapy with trained optometrists.ConclusionsDelayed post-traumatic abducens palsy is concerning for DAI and secondary axotomy. Multidisciplinary assessment imparts the ability to evaluate for all possible causes and provide additional specialized care for recovery.

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A challenging presentation of invasive nasopharyngeal sarcomatoid carcinoma

BMJ Case Reports ◽

10.1136/bcr-2018-226168 ◽

2019 ◽

Vol 12 (7) ◽

pp. e226168

Author(s):

Alexander Yao ◽

Haroon Saeed ◽

Gavin Udall ◽

Vivek Kaushik ◽

Lip Wai Lee

Keyword(s):

Nerve Palsy ◽

Multidisciplinary Approach ◽

Concurrent Chemoradiotherapy ◽

Sarcomatoid Carcinoma ◽

Abducens Nerve ◽

Response To Treatment ◽

Intracranial Extension ◽

Limited Evidence ◽

Histological Appearance ◽

Nose And Throat

Sarcomatoid carcinoma is a rare clinical entity, especially when presenting in the nasopharynx. We describe the first documented case of nasopharyngeal sarcomatoid carcinoma with intracranial extension in a 59-year-old Caucasian man presenting with severe bifrontal headache and diplopia, secondary to left abducens nerve palsy. We highlight some of the major diagnostic challenges and describe its unusual histological appearance. We outline the importance of a multidisciplinary approach to his management, which includes input from the medicine, neurosurgery, Ear, Nose and Throat (ENT), pathology, radiology, oncology and respiratory teams. In the context of limited evidence, we then describe the rationale to proceed with induction chemotherapy followed by concurrent chemoradiotherapy. Although there was a partial response to treatment, it was not sufficient enough to allow subsequent surgical clearance. The plan going forward is to palliate with chemotherapy as and when the disease progresses.

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Abducens Nerve Palsy as Initial Manifestation of Chronic Subdural Hematoma: Case Report

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0037-1603107 ◽

2017 ◽

Vol 38 (04) ◽

pp. 315-318

Author(s):

Marcelo José Silva Magalhães ◽

Henrique Nunes Pereira Oliva ◽

Getúlio Paixão Pereira ◽

Lucas Gabriel Quadros Ramos ◽

Henrique Caires Souza Azevedo

Keyword(s):

Subdural Hematoma ◽

Nerve Palsy ◽

Chronic Subdural Hematoma ◽

Abducens Nerve ◽

Abducens Nerve Palsy ◽

Systemic Hypertension ◽

Abducens Palsy ◽

Sixth Cranial Nerve ◽

Initial Manifestation ◽

Rare Finding

AbstractChronic subdural hematoma (CSDH) is a form of progressive intracranial hemorrhage, typically associated with cases of trauma. The manifestation of this comorbidity with abducens palsy is a rare finding. The present work aims to describe the case of an adult patient with abducens nerve palsy as a manifestation of CSDH. Chronic subdural hematoma is most commonly found in elderly patients, with systemic hypertension as a manifestation. The relation with the sixth cranial nerve is unusual and draws attention to the case reported. In addition, the prognosis is positive, since trepanation and drainage surgery was performed, as it is recommended in the literature.

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A rare case of post traumatic isolated bilateral abducens nerve palsy

Romanian Neurosurgery ◽

10.2478/romneu-2014-0068 ◽

2014 ◽

Vol 21 (4) ◽

pp. 497-499

Author(s):

Manish Jaiswal ◽

Saurabh Jain ◽

Ashok Gandhi ◽

Achal Sharma ◽

R.S. Mittal

Keyword(s):

Rare Case ◽

Nerve Palsy ◽

Abducens Nerve ◽

Abducens Nerve Palsy ◽

Resonance Imaging ◽

Intracranial Lesion ◽

Mri Brain ◽

Post Traumatic ◽

Magnetic Resonance Imaging Mri ◽

Bilateral Abducens

Abstract Although unilateral abducens nerve palsy has been reported to be as high as 1% to 2.7% of traumatic brain injury, bilateral abducens nerve palsy following injury is extremely rare. In this report, we present the case of a patient who developed isolated bilateral abducens nerve palsy following minor head injury. He had a Glasgow Coma Score (GCS) of 15 points. Computed tomography (CT) images & Magnetic Resonance Imaging (MRI) brain demonstrated no intracranial lesion. Herein, we discuss the possible mechanisms of bilateral abducens nerve palsy and its management.

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Bilateral abducens palsy in closed head injury: A comprehensive review of literature based on a case report

Asian Journal of Medical Sciences ◽

10.3126/ajms.v12i10.38006 ◽

2021 ◽

Vol 12 (10) ◽

pp. 164-170

Author(s):

Sandeep B V ◽

Rekha K R ◽

Manpreet Singh Banga ◽

Anantha Kishan ◽

Vittal I Nayak ◽

...

Keyword(s):

Head Injury ◽

Nerve Injury ◽

Nerve Palsy ◽

Closed Head Injury ◽

Abducens Nerve ◽

Nerve Injuries ◽

Abducens Palsy ◽

Closed Head ◽

Bilateral Abducens Palsy ◽

Bilateral Abducens

Isolated bilateral sixth nerve palsies are rare, particularly in the setting of trauma. Most post-head injury cases with bilateral abducens palsy involve either basal skull fractures, particularly clival fractures. We present a case of bilateral abducens palsy after closed head injury in a young male who presented to the emergency department and a comprehensive literature review based on our clinical case. A Medline search for bilateral abducens palsy in closed head injury showed 89 results. Articles were excluded if crush head injury, non-traumatic bilateral abducens nerve palsy, associated vascular malformations were reported. After thorough search and filtering of those articles, fifty-one publications were found which reported and discussed about traumatic bilateral abducens palsy with closed head injury. In these 51 articles, a total of 139 cases were recorded. Several theories have been postulated to explain mechanisms of abducens nerve injury in trauma both in immediate and delayed settings. In our case, patient presented with immediate onset of bilateral abducens palsy. On imaging, clival fracture was seen in CT brain, which can be attributed for the nerve injury. Cases with retroclival extradural haematoma had higher chances of multiple cranial nerve injuries. Cases with multiple basal skull fracture involving petrous temporal bone fracture had higher chances of facial nerve injury. Along with bilateral involvement, the poorer outcome for recovery can be related with the severity of the adduction deficit. Our case showed no improvement in bilateral abduction during follow-up at 6 months. Clinical presentation of traumatic bilateral abducens nerve palsy is rare following closed head trauma and is usually associated with other injuries which are incompatible with life. It can be associated with other nerve injuries depending on basal skull fractures.

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