Abducens Palsy Following Shunting for Hydrocephalus

Abstract

Over a period of 12 years, 80 patients underwent ventricular shunting for normal pressure hydrocephalus. Three developed sixth cranial nerve palsy in the first two weeks after surgery. This uncommon complication is usually transitory following the same pattern of abducens palsy after lumbar puncture or spinal anesthesia. Traction on the nerve with local ischemia has been involved as the responsible mechanism in both instances. RESUME: Paralysie du droit externe de I'oeil a la suite d'une derivation pour hydrocephalic. Sur une periode de 12 ans, 80 patients ont subi une derivation ventriculaire pour une hydrocephalic normotensive. Trois ont developpe une paralysie du sixieme nerf cranien dans les deux premieres semaines apres la chirurgie. Cette complication pcu frequente est habituellement transitoire et evolue comme la paralysie du droit externe survenant apres une ponction lombaire ou une anesthesie spinale. Une traction du nerf accompagnee d'ischemie locale a ete invoquee comme etant le mechanisme responsable dans les deux cas.Can. J. Neurol. Sci. 1993: 20: 123-125 The causes of abducens palsy are multiple and have been described before in the medical literature.1 -2 Nevertheless, its occurrence after ventricular shunting for normal pressure hydrocephalus (NPH) is so unusual that it deserves special attention. CASE REPORTS Patient 1A 69-year-old male presented with a 4-year history of unsteady gait, progressive memory impairment and recent onset of urinary incontinence. On examination there was difficulty recalling current events, gait apraxia and hyperreflexia of the lower extremities. Computerized tomography (CT) of the brain demonstrated ventricular dilatation. The results of an isotope cisternogram and lumbar subarachnoid infusion test suggested a diagnosis of NPH. A ventriculoatrial shunt was placed and the opening pressure was 18 cm of CSF. A Pudenz valve with a closing pressure of 5 cm of H 2 0 was used. Postoperative CT scan showed marked decrease in the ventricular size and brain atrophy.Nine days after surgery the patient complained of nausea and headache followed by double vision when looking towards the right side. The right eye had limited abduction consistent with a sixth nerve palsy. Two days later the headache and nausea disappeared; however the right abducens palsy persisted for nine weeks. His gait, urinary incontinence, and memory improved gradually. Patient 2A 69-year-old priest with a five-year history characterized by difficulty walking and progressive memory loss was admitted to our institution. Physical examination revealed minimal impairment of recent memory and an abnormal gait characterized by a wide base with short, unsteady steps. The lone was increased in the lower extremities with associated hyperreflexia. CT scan of the brain showed ventricular dilatation. Magnetic resonance imaging (MRI) disclosed a smooth, hyperintense border around the ventricjes and marked signal loss in the aqueduct. MRI cine was compatible with NPH. A lumbar puncture was not done as part of h...

Case report: Epidural blood patch in the treatment of abducens palsy after a dural puncture

“…[7][8][9] Sixth nerve palsy has been observed in various conditions associated with loss in CSF pressure. In addition to diagnostic lumbar puncture, neuraxial anesthesia, contrast myelography, 10 intrathecal glucocorticoid injection, 11 ventricular shunting for hydrocephalus, 12 spontaneous intracranial hypotension 13 and implantation of an intrathecal drug delivery device 14 may all lead to abducens nerve palsies. A constant leak of CSF through the dura leads to intracranial hypotension.…”

Abducens Nerve Palsy after Lumbar Spinal Fusion Surgery with Inadvertent Dural Tearing

“…One concerns cerebrospinal fluid (CSF) leakage, such as, during lumbar puncture, spinal anesthesia, ventricular shunting for normal pressure hydrocephalus, and during surgery on a spinal cord tumor 2,5,6,9,11,14) . The most common side effect of CSF leakage is a post-dural puncture headache (PDPH), which commonly occurs within 12-24 hours of puncture.…”

Unveiling the vulnerability of the human abducens nerve: insights from comparative cranial base anatomy in mammals and primates

“…In this clinical setting, the abducens nerve may become necrotic as it enters the gulfar segment due to its rostral fixation by the osteofibrous elements of Dorello’s canal ( Umansky et al, 1991 ; Hanson et al, 2004 ). This pathophysiological mechanism may also underlie abducens nerve palsy in the clinical setting of decreased intracranial pressure ( Bryce-Smith and Macintosh, 1951 ; Insel et al, 1980 ; Espinosa et al, 1993 ; Follens et al, 2001 ; Niedermüller et al, 2002 ; Arcand et al, 2004 ; Azarmina and Azarmina, 2013 ; Hofer and Scavone, 2015 ), trauma ( Schneider and Johnson, 1971 ; Takagi et al, 1976 ; Uzan et al, 1996 ; Ozveren et al, 2001 ; Sam et al, 2004 ), or space-occupying lesions ( Collier, 1904 ).…”