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

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.

Four-dimensional digital subtraction angiography for exploration of intraosseous arteriovenous fistula in the sphenoid bone

Background: Intraosseous arteriovenous fistula (AVF) is a rare clinical entity that typically presents with symptoms from their effect on surrounding structures. Here, we report a case of intraosseous AVF in the sphenoid bone that presented with bilateral abducens palsy. Case Description: A previously healthy man presented with tinnitus for 1 month, and initial imaging suspected dural AVF of the cavernous sinus. Four-dimensional digital subtraction angiography (4D-DSA) imaging and a three-dimensional (3D) fused image from the bilateral external carotid arteries revealed that the shunt was in a large venous pouch within the sphenoid bone that was treated through transvenous coil embolization. His symptoms improved the day after surgery. Conclusion: This is a case presentation of intraosseous AVF in the sphenoid bone and highlights the importance of 4D-DSA and 3D fused images for planning the treatment strategy.

Miller Fisher syndrome and polyneuritis cranialis in COVID-19

ObjectiveTo report 2 patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented acutely with Miller Fisher syndrome and polyneuritis cranialis, respectively.MethodsPatient data were obtained from medical records from the University Hospital “Príncipe de Asturias,” Alcalá de Henares, and the University Hospital “12 de Octubre,” Madrid, Spain.ResultsA 50-year-old man presented with anosmia, ageusia, right internuclear ophthalmoparesis, right fascicular oculomotor palsy, ataxia, areflexia, albuminocytologic dissociation, and positive testing for anti-GD1b–immunoglobulin G antibody. Five days previously, he had developed a cough, malaise, headache, low back pain, and fever. A 39-year-old man presented with ageusia, bilateral abducens palsy, areflexia, and albuminocytologic dissociation. Three days previously, he had developed diarrhea, a low-grade fever, and poor general condition. Oropharyngeal swab test for SARS-CoV-2 by qualitative real-time reverse transcriptase PCR assay was positive in both patients and negative in the CSF. The first patient was treated with IV immunoglobulin and the second with acetaminophen. Two weeks later, both patients made a complete neurologic recovery, except for residual anosmia and ageusia in the first case.ConclusionsOur 2 cases highlight the rare occurrence of Miller Fisher syndrome and polyneuritis cranialis during the coronavirus disease 2019 (COVID-19) pandemic. These neurologic manifestations may occur because of an aberrant immune response to COVID-19. The full clinical spectrum of neurologic symptoms in patients with COVID-19 remains to be characterized.