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BACKGROUND: Unlike syringomyelia, syringobulbia is not commonly observed in pediatric patients with Chiari malformation type I (CMI). Previous series have reported the incidence of syringobulbia as between 3% and 4% in these patients. Presentation is typically chronic, with the slow onset of neurological symptoms and cranial nerve (CN) palsies resulting from lower brainstem involvement. The authors report the first case of a pediatric patient with simultaneous CMI, syringobulbia, and unilateral CN VII palsy. OBSERVATIONS: A 7-year-old male presented with right facial weakness in addition to headaches, ataxia, urinary incontinence, and falls. Magnetic resonance imaging revealed CMI with a syrinx of the cervicothoracic spine and syringobulbia. Posterior fossa decompression with duraplasty was performed without complications, and the patient was discharged home on postoperation day 5. At the 3-week follow-up, the patients neurological deficits had largely subsided. At the 3-month follow-up, his CN VII palsy and syringobulbia had completely resolved. LESSONS: Pediatric CMI patients with syringomyelia are at risk for developing syringobulbia and brainstem deficits, including unilateral facial palsy. However, craniocervical decompression can prove successful in treating such deficits.

Objective: This study aimed to investigate the clinical factors that predict abnormal radiographic findings in adults with acute onset binocular diplopia. Methods: Medical records of consecutive patients aged >20 years who presented with acute binocular diplopia were retrospectively reviewed. Patients were divided into positive and negative groups according to radiographic findings. Demographic and clinical characteristics were compared. The risk factors for positive radiographic findings were investigated, and the area under the receiver operating characteristic curve (AUC) was calculated. Results: Among 242 patients (145 males and 97 females), 44 (18.2%) were in the positive group and 198 (81.8%) in the negative group. Patients in the positive group were older (p = 0.005) and had more vasculopathic risk factors (p = 0.038). Severe duction limitation (>50% reduction in motility) was present in 90.9% of patients in the positive group and 56.1% in the negative group (p < 0.001). Abnormal slit lamp findings and pupillary exam abnormalities were also more frequent in the positive group than in the negative group (p = 0.027 and p = 0.036, respectively). Older age, higher intraocular pressure, abnormal slit-lamp findings, exophthalmos, and duction limitation were identified as risk factors for positive radiographic findings. A predictive model generated an AUC of 0.772. Conclusion: Older age and vasculopathic risk factors were associated with underlying radiographic pathologies, supporting the recommendation that neuroimaging should not be delayed in those patients. Careful ophthalmic evaluations may guide diagnosis and decision-making for immediate neuroimaging in cases of diplopia. [ABSTRACT FROM AUTHOR]

The cavernous sinus is a complex anatomical space with multiple neuro-vascular structures. Due to its anatomical complexity, patients with internal carotid artery aneurysms within the cavernous sinus can present with a variety of symptoms. This is a case presentation of a 73-year-old patient with a right-sided intracavernous internal carotid artery aneurysm who declined neurosurgical intervention, opting for conservative management. The evolution of symptoms is highlighted, from intermittent changes in vision to further development of proptosis, associated with the reduction of vision, Horner’s syndrome, sixth nerve palsy, and disc swelling. This culminated in a severe reduction in vision due to optic atrophy, restriction of eye movements with maintained adduction only, dilatation of the pupil, and forehead/cheek hypoesthesia. [ABSTRACT FROM AUTHOR]

Calcifying pseudoneoplasm of the neuraxis (CAPNON) is an uncommon entity and a rare cause of third cranial nerve palsy. We review the case of a 17-year-old male with a 9-month history of progressive left third cranial nerve palsy. Cerebral magnetic resonance image showed a left clinoidal lesion with low signal intensity in T2 and T1 sequences with signs of calcification in the computed tomography and without vascular lesion in AngioMRI. A left pterional approach was performed with posterior clinoidectomy and total resection of the lesion. Calcifying pseudoneoplasm of the neuraxis is an infrequent pathology that presents in the skull base and spine that requires surgical treatment in the presence of compressive phenomena and differential diagnosis as meningioma, chordoma, and metastasis should be considered. [ABSTRACT FROM AUTHOR]

Introduction: Schwannomas are rare benign neurogenic tumours. About 25–45% of extracranial schwannomas are found in the head and neck region. In the head and neck, they can arise from various cranial, peripheral and autonomic nerves. Due to this, they have varied clinical presentations. Material and Methods: This retrospective cohort includes 97 patients diagnosed with extra cranial head and neck schwannoma, and operated in the Otolaryngology and Head & Neck Surgery department, from 2013 to 2022. The parameters observed were the age and gender distribution, location, nerve of origin, size, pressure symptoms, cranial palsies, post-operative symptoms, recurrence and complications. The data were collected from the institute's electronic records. Results: The median age of the study population was 36 years; among them, 51 were men and 46 were women. The most common tumour location was parapharynx. The patients had varied head and neck symptoms, of which 23.7% had nerve paresis at presentation. Transcervical surgical approaches was most used. New onset cranial nerve paresis immediately post-surgery was noted in 22.7%. Recurrence was noted in 2% of cases. Conclusions: Extra cranial schwannomas are uncommon neoplasms and have varied presentations. Comprehensive evaluation with appropriate imaging should be done in all cases. Though benign, patients can present with nerve paresis. Recurrence is uncommon after complete resection. [ABSTRACT FROM AUTHOR]

Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality. This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus , streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation. An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease. [ABSTRACT FROM AUTHOR]

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Objectives: This study aimed to investigate the association between intracerebral aneurysms and cranial nerve (CN) palsies, focusing on nerves other than the oculomotor nerve. It sought to determine the prevalence, risk factors, and clinical outcomes of these nerve palsies and compare the effectiveness of microsurgical clipping versus endovascular coiling in restoring nerve function. Methodology: Following PRISMA guidelines, a comprehensive literature search was conducted using databases like PubMed, Scopus, and Google Scholar, covering studies from 1975 to April 2024. The inclusion criteria targeted patients with non-oculomotor nerve palsies diagnosed with cerebral aneurysms. Studies published before 1975 and non-English studies were excluded. Data extraction included study design, patient characteristics, and intervention outcomes. The Joanna Briggs Institute and Newcastle-Ottawa scales were used to assess study quality. Data were synthesized narratively and statistically analysed using SPSS v27. Results: The analysis included 47 patients (53.2% female, mean age 44.8 years). The internal carotid artery (ICA) was the most common aneurysm site (44.7%), and the abducent nerve (CN VI) was most frequently affected. Ruptured aneurysms had better recovery outcomes (88.9%) than unruptured ones (66.7%). Hypertension was present in 9.2%. Unilateral aneurysms were seen in 80.9%, with 76.6% having a single nerve palsy. Non-ruptured aneurysms accounted for 58.1%, and ruptured for 41.9% of associated cranial nerve palsies. Treatment included microsurgical approaches (42.6%), endovascular approaches (34%), combined approaches (6.4%), and conservative management (17%). Recovery of the palsy was observed in 75.6%, with endovascular procedures showing higher recovery (93.3%) compared to conservative treatment (28.6%). Conclusion: Intracerebral aneurysms are significantly associated with non-oculomotor CN palsies. Endovascular procedures yield higher recovery rates than conservative management, particularly in ruptured aneurysms. Timely and appropriate treatment is crucial for improving nerve function recovery in these patients. [ABSTRACT FROM AUTHOR]

COVID-19 can cause a wide range of ocular manifestations. The most common ocular manifestation is conjunctivitis. Neuro-ophthalmic presentations of COVID-19 are rare. Case reports suggest that COVID-19 infection can cause cranial nerve palsy, including nerves that regulate ocular movements. The present studypresented a case of fourth nerve palsy in a healthy and asymptomatic COVID-19-infected child. A healthy 10-year-old boy was referred to our eye clinic with a complaint of recent abnormal head posture and squint. His past medical history was unremarkable, and he had not received any medication or vaccinations within the last few weeks. No history of ocular or head trauma was observed. The patient was afebrile and had no respiratory symptoms. A comprehensive ocular examination was performed. All examinations, including slit-lamp, pupils, eyelids, and optic nerve heads, were normal. In ocular motor evaluations, left eye hyperdeviation was observed. Because of the history of COVID-19 in the mother of the child, he was referred to an infectious disease specialist and was tested for SARS-COV-2 with a nasopharyngeal swab specimen. The test was positive and SARS-COV-2 was detected. In addition, the patient was referred to a pediatric neurology department. Brain and orbital MRI was performed, and it was unremarkable. The post-viral fourth nerve palsy is uncommon, and post-COVID-19 has not been reported before. Clinicians should consider this infection in any recent strabismus in pediatrics. The children rarely complain of diplopia, and a recent abnormal head posture may be a sign of acquired strabismus. [ABSTRACT FROM AUTHOR]

ObjectiveThis study aimed to investigate the clinical factors that predict abnormal radiographic findings in adults with acute onset binocular diplopia.MethodsMedical records of consecutive patients aged >20 years who presented with acute binocular diplopia were retrospectively reviewed. Patients were divided into positive and negative groups according to radiographic findings. Demographic and clinical characteristics were compared. The risk factors for positive radiographic findings were investigated, and the area under the receiver operating characteristic curve (AUC) was calculated.ResultsAmong 242 patients (145 males and 97 females), 44 (18.2%) were in the positive group and 198 (81.8%) in the negative group. Patients in the positive group were older (p = 0.005) and had more vasculopathic risk factors (p = 0.038). Severe duction limitation (>50% reduction in motility) was present in 90.9% of patients in the positive group and 56.1% in the negative group (p

Abstract Background Cranial nerve palsy (CNP) is a common complication of traumatic brain injury (TBI). Despite a high incidence of TBI in Nepal (382 per 100,000), literature on the specific management and outcome of CNP is lacking. This study aimed to examine the outcomes of TBI patients involving single versus multiple CNP. Methods A retrospective chart review of 170 consecutive TBI patients admitted to the tertiary neurosurgical center in Nepal between April 2020 and April 2022 was conducted. Demographic, clinical, and etiological characteristics; imaging findings; and management strategies were recorded, compared, and analyzed using descriptive statistics. The Glasgow Outcome Scale Extended (GOSE) was used to measure the outcomes in two groups of patients (single and multiple CNP) at 3 months. Results Out of 250 eligible patients, 80 were excluded and CNP was noted in 29 (17.1%) of the remaining 170. The median age was 34.9 years, and falls (60.6%) were the most common cause of trauma. TBI severity was categorized based on GCS: mild (82.4%), moderate (15.9%), and severe (1.8%). Cranial nerve involvement was seen in 29 (17.05%) patients: single cranial nerve involvement in 26 (89.65%) and multiple nerve involvement in 3 (10.34%). The most common isolated cranial nerve involved was the oculomotor nerve (37.9%). CT findings revealed a maximum of skull fractures with no significant association between CNP and CT findings. Conclusions CNP is a common consequence of TBI with the most common etiology being falls followed by RTA. Single CNP was more common than multiple CNP with no significant difference in the outcome in the 3-month GOSE score. Further research is needed to determine the burden of traumatic CNP and establish specific management guidelines for different types of CNP.

Introduction: This study aimed to emphasize the importance of cranial nerve (CN) palsies in spontaneous cervical artery dissection (sCeAD). Methods: A search term-based literature review was conducted on "cervical artery dissection" and "cranial nerve palsy." English and German articles published until October 2023 were considered. Results: Cranial nerve (CN) palsy in sCeAD is evident in approximately 10% of cases. In the literature, isolated palsies of CN II, III, VII, IX, X, and XII have been reported, while CN XI palsy only occurs in combination with other lower cranial nerve palsies. Dissection type and mural hematoma localization are specific to affected CN as CN palsies of II or III are solely evident in those with stenoocclusive vessel pathologies located at more proximal segments of ICA, while those with CN palsies of IX, X, XI, and XII occur in expansive sCeAD at more distal segments. This dichotomization emphasizes the hypothesis of a different pathomechanism in CN palsy associated with sCeAD, one being hypoperfusion or microembolism (CN II, III, and VII) and the other being a local mass effect on surrounding tissue (CN IX, X, XI, and XII). Clinically, the distinction between peripheral palsies and those caused by brainstem infarction is difficult. This differentiation is key, as, according to the reviewed cases, peripheral cranial nerve palsies in sCeAD patients mostly resolve completely over time, while those due to brainstem stroke do not, making cerebrovascular imaging appraisal essential. Discussion: It is important to consider dissections as a potential cause of peripheral CN palsies and to be aware of the appropriate diagnostic pathways. This awareness can help clinicians make an early diagnosis, offering the opportunity for primary stroke prevention. [ABSTRACT FROM AUTHOR]

Background: A case of retropharyngeal abscess complicated by both artery and nerve injury has rarely been reported. Methods: A 36‐year‐old woman suddenly presented with right eye visual loss, dilated pupil, reduced direct light reflex, ptosis and ocular motility disorder on the side of inflammation progression, and was diagnosed with retropharyngeal abscess due to Fusobacterium necrophorum. The patient was treated only with antibiotics and, no further surgery was necessary but tracheotomy. Four months later, MRA showed right ICA occlusion and left ICA stenosis. MRI revealed continuous spread of inflammation due to the abscess from the retropharyngeal to the intracranial space. Results: These severe complications would be attributed to an endothelial damage to the arterial wall and an ischemic neuropathy caused by inflammation and thrombogenesis due to Fusobacterium necrophorum. Conclusions: This case should provide a better understanding of the mechanism of vascular and cranial nerve injury due to retropharyngeal infections, and highlights the need for early antibiotic therapy and repeated vascular evaluation. [ABSTRACT FROM AUTHOR]

Introduction: Clinical manifestations of cranial nerve palsies are of great importance, and surgeons should consider them before planning surgical protocol. Materials and Methods: This retrospective study was conducted on preoperative hospital records of 598 Iranian patients with different types of extraocular muscle palsy, including third (90 patients), fourth (501 patients), and fifth (7 patients) nerve palsy at Farabi Hospital, Tehran Province, Iran. Results: In terms of fourth nerve palsy, the mean spherical equivalent (SE) in the right and left eye was 0.23±1.51 and 0.19±1.45 diopter, respectively. Also, the mean angle of vertical deviation was 15.54±8.85 Δ at near and 15.66±8.93 Δ at far. In patients with third nerve palsy, the mean SE in the right and left eye was -0.02±2.08 and 0.08±1.95 diopter, respectively. Also, the mean angle of vertical deviation was 17.8±17.4 Δ at near and 17.8±17.5 Δ at far. In terms of six nerve palsy, the mean SE in the right and left eye was -1.27±3.37 and -1.08±2.52 diopter, respectively. Also, the mean angle of esotropia was 32.4±7.7 Δ at near and 33±6.7 Δ at far. The frequency of amblyopia in patients with third, fourth, and sixth nerve palsies was 21 patients (23.3%), 70(14%), and 4(57.1%), respectively. Conclusion: The clinical characteristics of patients with different types of EOM palsy are remarkably different, which can be attributed to the different properties of these kinds of deviations. [ABSTRACT FROM AUTHOR]

Background: Cranial nerve palsy (CNP) is a common complication of traumatic brain injury (TBI). Despite a high incidence of TBI in Nepal (382 per 100,000), literature on the specific management and outcome of CNP is lacking. This study aimed to examine the outcomes of TBI patients involving single versus multiple CNP. Methods: A retrospective chart review of 170 consecutive TBI patients admitted to the tertiary neurosurgical center in Nepal between April 2020 and April 2022 was conducted. Demographic, clinical, and etiological characteristics; imaging findings; and management strategies were recorded, compared, and analyzed using descriptive statistics. The Glasgow Outcome Scale Extended (GOSE) was used to measure the outcomes in two groups of patients (single and multiple CNP) at 3 months. Results: Out of 250 eligible patients, 80 were excluded and CNP was noted in 29 (17.1%) of the remaining 170. The median age was 34.9 years, and falls (60.6%) were the most common cause of trauma. TBI severity was categorized based on GCS: mild (82.4%), moderate (15.9%), and severe (1.8%). Cranial nerve involvement was seen in 29 (17.05%) patients: single cranial nerve involvement in 26 (89.65%) and multiple nerve involvement in 3 (10.34%). The most common isolated cranial nerve involved was the oculomotor nerve (37.9%). CT findings revealed a maximum of skull fractures with no significant association between CNP and CT findings. Conclusions: CNP is a common consequence of TBI with the most common etiology being falls followed by RTA. Single CNP was more common than multiple CNP with no significant difference in the outcome in the 3-month GOSE score. Further research is needed to determine the burden of traumatic CNP and establish specific management guidelines for different types of CNP. [ABSTRACT FROM AUTHOR]

The article outlines the importance of differentiating between comitant and incomitant strabismus, highlighting that the latter may be due to cranial nerve palsies, which can be associated with significant risks. Topics include identifying red flags such as sudden onset or associated neurological symptoms, the importance of physical examination and specific tests like the Bruckner test, and appropriate follow-up actions including urgent referrals and neuroimaging when needed.

To assess the risk of dementia in individuals with newly diagnosed ocular motor cranial neuropathy (OMCN). A nationwide, population-based cohort study using authenticated data from the Korean National Health Insurance Service (KNHIS). This study included 60 781 patients with OMCN who received a diagnosis between 2010 and 2017 and were followed up through 2018, with an average follow-up of 3.37 ± 2.21 years with a 1-year lag. After excluding patients with disease related to oculomotor dysfunction preceding the OMCN diagnosis, a total of 52 076 patients with OMCN were established. Of these, 23 642 patients who had participated in the National Health Screening Program (NHSP) within 2 years before the OMCN diagnosis were included. After applying the exclusion criteria, the final cohort comprised 19 243 patients and 96 215 age and sex-matched control participants without OMCN. We identified patients with newly diagnosed OMCN in the KNHIS database and collected participant characteristics from the health checkup records of the NHSP. The study end point was determined by the first claim with a dementia diagnostic code and antidementia medications. The association of OMCN with dementia risk was examined using Cox proportional hazards regression analysis, adjusting for potential confounding factors. The main outcome measures were hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause dementia (ACD), Alzheimer's disease (AD), and vascular dementia (VaD) development in patients with OMCN relative to those without OMCN. Patients with newly diagnosed OMCN demonstrated higher metabolic comorbidities than those without OMCN. New OMCN was associated with an elevated risk of ACD (HR, 1.203; 95% CI, 1.113–1.300), AD (HR, 1.137; 95% CI, 1.041–1.243), and VaD (HR, 1.583; 95% CI, 1.286–1.948), independent of potential confounding factors. The younger age groups exhibited a stronger association between OMCN and ACD (HR, 8.690 [< 50 years] vs. 1.192 [≥ 50 years]; P = 0.0004; HR, 2.517 [< 65 years] vs. 1.099 [≥ 65 years]; P < 0.0001). This nationwide population-based study assessed the association between OMCN and dementia risk. Our results demonstrated a robust relationship between OMCN and the risk of dementia, particularly in the younger population. The author(s) have no proprietary or commercial interest in any materials discussed in this article. [ABSTRACT FROM AUTHOR]

Introduction: Immune checkpoint inhibitors are the mainstay of treatment in patients with unresectable or metastatic melanoma. Combination immunotherapy with ipilimumab and nivolumab has shown to improve survival outcomes as compared to single agent immunotherapy in these patients. Neurological immune-related adverse effects (irAEs) are uncommon and cranial nerve palsies are seen even more infrequently. Case presentation: A 66-year-old woman with a background of metastatic, unresectable melanoma with supraclavicular and axillary lymph nodal involvement presented with a headache, photophobia and diplopia 3 weeks after her first cycle of ipilimumab and nivolumab. She was subsequently diagnosed with a left-sided cranial nerve VI palsy and treated with high dose oral steroids and steroid eye drops, with complete resolution of symptoms. She also experienced Grade 3 dermatitis requiring topical steroids, Grade 2 hypothyroidism and vitiligo. She continues to have an excellent clinical and radiological response, despite further immunotherapy being suspended. Conclusion: This is the first reported UK case of immunotherapy-induced isolated cranial nerve VI palsy. Multiple irAEs are more common with combination immunotherapy and its occurrence is associated with more favourable outcomes in melanoma. Immunotherapy continues to revolutionise oncological care, but clinicians must be cognizant of unpredictable irAEs, which may require prompt assessment and intervention. [ABSTRACT FROM AUTHOR]

Simple Summary: Established risk factors for primary malignant brain tumors include hereditary syndromes, family history of brain tumors, head trauma, smoking, alcohol consumption, radiation exposure, electromagnetic wave exposure, infections, inflammation, and exposure to toxic substances. However, the impact of acquired ocular motor cranial nerve palsies on subsequent primary malignant brain tumors remains underexplored. Our research presents an exhaustive analysis of data from the Korea National Health Insurance Service from 2010 to 2017. Correlation between ocular motor cranial nerve palsies and emergence of primary malignant brain tumors within a Korean population was investigated. Our findings emphasize an amplified risk of primary malignant brain tumors in patients diagnosed with ocular motor cranial nerve palsies, particularly among women aged below 65. The aim of this study was to investigate the association between ocular motor cranial nerve palsies (OMCNP) and the occurrence of primary malignant brain tumors in a Korean population, using the national sample cohort database from Korea National Health Insurance Service (KNHIS). KNHIS data between 2010 and 2017 were analyzed. Our sample encompassed 118,686 participants, including 19,781 from a recently diagnosed OMCNP cohort and 98,905 from a matched control cohort through a 1:5 propensity score matching based on age and gender. To counteract the issue of reverse causation, we integrated a one-year time lag in our sensitivity analysis. Study participants were followed up until 31 December 2019. Cox proportional hazard regression analysis was used to compute the adjusted hazard ratio (HR) for primary malignant brain tumors according to the OMCNP diagnosis. Additionally, we performed a subgroup analysis to discern effects of various factors on the association between OMCNP and primary malignant brain tumors. HR for primary malignant brain tumors was 3.272 (95% confidence interval [CI]: 2.294 to 4.665) in the OMCNP cohort compared to the control cohort in a fully adjusted model for age, sex, socio-economic status, smoking, drinking, regular physical exercise, hypertension, diabetes, dyslipidemia, obesity, chronic kidney disease, and human immunodeficiency virus infection. Further subgroup analysis revealed that the risk of primary malignant brain tumors was significantly increased in women with OMCNP compared to men with OMCNP (HR: 5.118 in women vs. 2.441 in men, p = 0.0440), and in those aged <65 years than in those aged ≥65 years (HR: 6.951 in age < 65 years vs. 1.899 in age ≥ 65 years, p = 0.0006). Our population-based cohort study demonstrated a significantly increased risk of subsequent primary malignant brain tumors in patients with OMCNP. Particularly, OMCNP-afflicted women aged below 65 manifested a heightened probability of developing primary malignant brain tumors compared to those devoid of OMCNP. [ABSTRACT FROM AUTHOR]

Purpose : Minimally invasive and surgical spine procedures are commonplace with various risks and complications. Cranial nerve palsies, however, are infrequently encountered, particularly after procedures such as lumbar punctures, epidural anesthesia, or intrathecal injections, and are understandably worrisome for clinicians and patients as they may be interpreted as secondary to a sinister etiology. However, a less commonly considered source is a pneumocephalus which may, in rare cases, abut cranial nerves and cause a palsy as a benign and often self-resolving complication. Here, we present the case of a patient who underwent an intrathecal methotrexate infusion for newly diagnosed non-Hodgkin's T -cell lymphoma and subsequently developed an abducens nerve palsy due to pneumocephalus. We highlight the utility of various imaging modalities, treatment options, and review current literature on spinal procedures resulting in cranial nerve palsies attributable to pneumocephalus presenting as malignant etiologies. [ABSTRACT FROM AUTHOR]

To compare rates of diagnosis of neuro-ophthalmic conditions across the Coronavirus Disease 2019 (COVID-19) pandemic with pre-pandemic levels. Multicenter, retrospective, observational study. Patients seen for eye care between March 11, 2019, and December 31, 2021. A multicenter electronic health record database, Sight Outcomes Research Collaborative (SOURCE), was queried for new diagnoses of neuro-ophthalmic conditions (cranial nerve [CN] III, IV, VI, and VII palsy; diplopia; and optic neuritis) and new diagnoses of other ophthalmic conditions from January 1, 2016, to December 31, 2021. Data were divided into 3 periods (pre-COVID, pre-COVID vaccine, and after introduction of COVID vaccine), with a 3-year look-back period. Logistic regressions were used to compare diagnosis rates across periods. Two-sample z-test was used to compare the log odds ratio (OR) of the diagnosis in each period with emergent ocular conditions: retinal detachment (RD) and acute angle-closure glaucoma (AACG). Diagnosis rate of neuro-ophthalmic conditions in each study period. A total of 323 261 unique patients (median age 59 years [interquartile range, 43–70], 58% female, 68% White) across 5 academic centers were included, with 180 009 patients seen in the pre-COVID period, 149 835 patients seen in the pre-COVID vaccine period, and 164 778 patients seen in the COVID vaccine period. Diagnosis rates of CN VII palsy, diplopia, glaucoma, and cataract decreased from the pre-COVID period to the pre-vaccine period. However, the optic neuritis diagnoses increased, in contrast to a decrease in RD diagnoses (P = 0.021). By comparing the diagnosis rates before and after widespread vaccination, all eye conditions evaluated were diagnosed at higher rates in the COVID vaccination period compared with pre-COVID and pre-vaccine periods. The log OR of neuro-ophthalmic diagnosis rates across every period comparison were largely similar to emergency conditions (RD and AACG, P > 0.05). However, the log OR of cataract and glaucoma diagnoses were different to RD or AACG (P < 0.05) in each period comparison. Neuro-ophthalmic diagnoses had a similar reduction in diagnosis rates as emergent eye conditions in the first part of the pandemic, except optic neuritis. After widespread COVID-19 vaccination, all ophthalmic diagnosis rates increased compared with pre-pandemic rates, and the increase in neuro-ophthalmic diagnosis rates did not exceed the increase in RD and AACG diagnosis rates. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. [ABSTRACT FROM AUTHOR]

Background: Cranial nerve palsy (CNP) in patients with intracranial aneurysms (IAs) can impose significant burdens on a patient's quality of life. The literature has a paucity of reviews addressing patterns of overall reported cranial nerve (CN) involvement and outcomes in patients with IA. Methods: The literature systematically reviewed CNP at presentation in the setting of IA using PubMed, Web-of-Science, and Scopus according to the PRISMA guidelines. Results: Fifty-two studies reported a total of 513 patients with IA and 630 CNPs observed at presentation: oculomotor (58.25%), abducent (15.87%), optic (12.06%), trochlear (8.7%), and trigeminal (1.9%). Most common aneurysms are located in a posterior communicating artery (46%) and cavernous internal carotid artery (29.2%). Trends of CNP based on the rupture status of IAs showed that 80% were associated with unruptured IAs and 20% with ruptured IAs. Post-treatment of IA, 55% of patients had complete resolution of CNP, with most (89%; n = 134) resolving within the first 6 months. Stratified by CNP type: Complete resolution rate is 100% in CN VII-IX, 60% in CN VI, 59% in CN IV, 54% in CN III, 45% in CN V, and 43% in CN II. Conclusion: In patients with cranial nerve palsies attributed to IAs, the location and rupture status of the aneurysm could determine the type and severity of the nerve palsy. Most patients experienced favorable outcomes in terms of their resolution and long-term function of the CNP after treatment of the IA. [ABSTRACT FROM AUTHOR]

Background: Cranial nerve (CN) palsy may manifest as an initial presentation of intracranial aneurysms or due to the treatment. The literature reveals a paucity of studies addressing the involvement of the 6th CN in the presentation of cerebral aneurysms. Methods: Clinical patient data, aneurysmal characteristics, and CN 6th palsy outcome were retrospectively reviewed and analyzed. Results: Out of 1311 cases analyzed, a total of 12 cases were identified as having CN 6th palsy at the presentation. Eight out of the 12 were found in the unruptured aneurysm in the cavernous segment of the internal carotid artery (ICA). The other four cases of CN 6th palsy were found in association with ruptured aneurysms located exclusively at the posterior inferior cerebellar artery (PICA). For the full functional recovery of the CN 6th palsy, there was 50% documented full recovery in the eight cases of the unruptured cavernous ICA aneurysm. On the other hand, all four patients with ruptured PICA aneurysms have a full recovery of CN 6th palsy. The duration for recovery for CN palsy ranges from 1 to 5 months. Conclusion: The association between intracranial aneurysms and CN 6th palsy at presentation may suggest distinct patterns related to aneurysmal location and size. The abducent nerve palsy can be linked to unruptured cavernous ICA and ruptured PICA aneurysms. The recovery of CN 6th palsy may be influenced by aneurysm size, rupture status, location, and treatment modality. [ABSTRACT FROM AUTHOR]

Background This cohort study aims to examine the relationship between the occurrence of cranial nerve palsy (CNP) affecting the third, fourth, or sixth cranial nerve and the subsequent risk of stroke, with a particular focus on the modulating effect of age on this association. Methods and Results We established a cohort of individuals diagnosed with third, fourth, or sixth CNP who underwent national health screening within 2 years of diagnosis from 2010 to 2017. A control group was matched by sex and age at a ratio of 1:5. Participants were followed until December 31, 2019. We use multivariable Cox proportional hazards regression analyses to assess the association between ocular motor CNP and subsequent stroke stratified by age. Covariates including lifestyle, health behavior, underlying comorbidities, and Charlson comorbidity index score were also adjusted. Compared with the control group, the ocular motor CNP group had a higher risk of stroke after adjusting for potential confounders (hazard ratio [HR], 1.23 [95% CI,, 1.08–1.39]). The risk of stroke increased by 8.91 times in individuals with ocular motor CNP who were in their 30s (HR, 8.91 [95% CI, 1.63–48.66]). The risk increased by 2.49 times in those who were in their 40s, 1.78 times in those who were in their 50s, and 1.32 times in those who were in their 60s (HRs, 2.49, 1.78, and 1.32 [95% CI, 1.39–4.45, 1.31–2.42, and 1.08–1.62], respectively). However, for those who were in their 20s, 70s, or 80s, the incidence of stroke did not significantly increase. Conclusions Our study establishes an association between ocular motor CNP and an increased risk of stroke, particularly in young adults.

Background/objective: Oculomotor palsy is one of the most frequent neuro-ophthalmologic complications in patients with diabetes. Specifically, sixth nerve palsy is the most common. Case report: A 51-year-old female with a past medical history of type 1 diabetes on insulin and hypertension presented with complaints of worsening headache and diplopia. Physical exam was remarkable for recurrent sixth-nerve palsy. Patient was hemodynamically stable. Labs showed blood glucose of 367 mg/dL (70–100 mg/dL), an anion gap of 2 mmol/L (3–13 mmol/L), creatinine of 0.61 mg/dl (0.66–1.25 mg/dL), sodium of 129 mmol/L (135–145 mmol/L), and potassium of 4.4 mmol/L (3.5–5.1 mmol/L). Her hemoglobin A1C was 13.0 % Her complete blood count shows a white blood cell count of 6000/μL (3600-10,700/μL) and a hemoglobin of 14 g/dL (13.0–18.0 g/dL). Magnetic resonance venography of the head was negative for cerebral venous sinus thrombosis and magnetic resonance imaging of the brain was negative for acute abnormalities. Blood glucose readings improved during hospitalization after optimizing her insulin regimen. She was recommended to follow-up with outpatient endocrinology to discuss use of an insulin pump to better control her diabetes. Discussion: Sixth-nerve palsy is a frequent but lesser-known neuro-ophthalmologic complication of poorly controlled diabetic patients. Conclusion: Studies have shown a higher incidence of diabetes in patients with sixth-nerve palsy, warranting a more focused medical evaluation along with close observation and tighter control of blood glucose levels and hemoglobin A1C.

Background: Retroclival hematomas and clival fractures are not common, and retroclival hematoma is one of the types of posterior fossa extra-axial hematomas. The exact incidence is not known. They can be categorized into epidural or subdural hematomas based on their relationship to the tectorial membrane. In the literature, most cases occur in the pediatric population, and a few cases have been reported in the adult population as well. The etiology is related to accidental trauma in most cases. Others occur generally spontaneously due to coagulopathy, pituitary apoplexy, and ruptured aneurysms. Still, some remain idiopathic without an identifiable cause. Case presentation: This is a 28-year-old male patient who presented after sustaining a motor vehicle accident. He was a pedestrian walking by the side of a road when he was suddenly hit by a minibus. He lost consciousness immediately and was non-communicating after the trauma with right ear bleeding. GCS is 9/15, right pupil has cataract, and left pupil is midsized and reactive. A brain CT scan demonstrated retroclival hematoma extending from midclivus to the lower level of C2, right mastoid fracture, multiple post-traumatic subarachnoid hemorrhage, pneumocephalus, and transverse upper third clival fracture. This patient's GCS on the second day improved to 14/15. All cranial nerves are intact. Discharged on the 7th day with GCS 15/15. Conclusion: Retroclival hematomas and clival fractures are very rare in adults, most often reported in pediatric age groups, and mostly occur due to accidental trauma. Associated cranial nerve palsy is common and the management is non-surgical in most of the cases.

IntroductionThis study aimed to emphasize the importance of cranial nerve (CN) palsies in spontaneous cervical artery dissection (sCeAD).MethodsA search term-based literature review was conducted on “cervical artery dissection” and “cranial nerve palsy.” English and German articles published until October 2023 were considered.ResultsCranial nerve (CN) palsy in sCeAD is evident in approximately 10% of cases. In the literature, isolated palsies of CN II, III, VII, IX, X, and XII have been reported, while CN XI palsy only occurs in combination with other lower cranial nerve palsies. Dissection type and mural hematoma localization are specific to affected CN as CN palsies of II or III are solely evident in those with steno-occlusive vessel pathologies located at more proximal segments of ICA, while those with CN palsies of IX, X, XI, and XII occur in expansive sCeAD at more distal segments. This dichotomization emphasizes the hypothesis of a different pathomechanism in CN palsy associated with sCeAD, one being hypoperfusion or microembolism (CN II, III, and VII) and the other being a local mass effect on surrounding tissue (CN IX, X, XI, and XII). Clinically, the distinction between peripheral palsies and those caused by brainstem infarction is difficult. This differentiation is key, as, according to the reviewed cases, peripheral cranial nerve palsies in sCeAD patients mostly resolve completely over time, while those due to brainstem stroke do not, making cerebrovascular imaging appraisal essential.DiscussionIt is important to consider dissections as a potential cause of peripheral CN palsies and to be aware of the appropriate diagnostic pathways. This awareness can help clinicians make an early diagnosis, offering the opportunity for primary stroke prevention.

A 50-year-old hypertensive male presented with sudden onset drooping of the left upper eyelid of 28 days duration. Clinical examination revealed left-sided pupil involving third nerve palsy. Imaging studies detected a nonenhancing intrasellar area within the left para-midline anterior pituitary. The mass lesion was resected and the histological study was consistent with a diagnosis of pituitary adenoma complicated with pituitary apoplexy. There was a complete resolution of ptosis one month following the surgical procedure.

IntroductionImmune checkpoint inhibitors are the mainstay of treatment in patients with unresectable or metastatic melanoma. Combination immunotherapy with ipilimumab and nivolumab has shown to improve survival outcomes as compared to single agent immunotherapy in these patients. Neurological immune-related adverse effects (irAEs) are uncommon and cranial nerve palsies are seen even more infrequently.Case presentationA 66-year-old woman with a background of metastatic, unresectable melanoma with supraclavicular and axillary lymph nodal involvement presented with a headache, photophobia and diplopia 3 weeks after her first cycle of ipilimumab and nivolumab. She was subsequently diagnosed with a left-sided cranial nerve VI palsy and treated with high dose oral steroids and steroid eye drops, with complete resolution of symptoms. She also experienced Grade 3 dermatitis requiring topical steroids, Grade 2 hypothyroidism and vitiligo. She continues to have an excellent clinical and radiological response, despite further immunotherapy being suspended.ConclusionThis is the first reported UK case of immunotherapy-induced isolated cranial nerve VI palsy. Multiple irAEs are more common with combination immunotherapy and its occurrence is associated with more favourable outcomes in melanoma. Immunotherapy continues to revolutionise oncological care, but clinicians must be cognizant of unpredictable irAEs, which may require prompt assessment and intervention.

Introduction: Clinical manifestations of cranial nerve palsies are of great importance, and surgeons should consider them before planning surgical protocol. Materials and Methods: This retrospective study was conducted on preoperative hospital records of 598 Iranian patients with different types of extraocular muscle palsy, including third (90 patients), fourth (501 patients), and fifth (7 patients) nerve palsy at Farabi Hospital, Tehran Province, Iran. Results: In terms of fourth nerve palsy, the mean spherical equivalent (SE) in the right and left eye was 0.23±1.51 and 0.19±1.45 diopter, respectively. Also, the mean angle of vertical deviation was 15.54±8.85 Δ at near and 15.66±8.93 Δ at far. In patients with third nerve palsy, the mean SE in the right and left eye was -0.02±2.08 and 0.08±1.95 diopter, respectively. Also, the mean angle of vertical deviation was 17.8±17.4 Δ at near and 17.8±17.5 Δ at far. In terms of six nerve palsy, the mean SE in the right and left eye was -1.27±3.37 and -1.08±2.52 diopter, respectively. Also, the mean angle of esotropia was 32.4±7.7 Δ at near and 33±6.7 Δ at far. The frequency of amblyopia in patients with third, fourth, and sixth nerve palsies was 21 patients (23.3%), 70(14%), and 4(57.1%), respectively. Conclusion: The clinical characteristics of patients with different types of EOM palsy are remarkably different, which can be attributed to the different properties of these kinds of deviations.

Trigeminal neuralgia is the most common type of craniofacial neuralgia, characterized by paroxysmal lancinating electric shock-like pain confined to the somatosensory distribution of the trigeminal nerve. Fluoroscopy-guided Radiofrequency Ablation of Gasserian Ganglion (RFA-GG) is the commonly performed minimally invasive pain intervention in these patients. Various complications such as masseter weakness, corneal anesthesia, dysesthesia, anesthesia dolorosa, keratitis, and cranial nerve deficits have been reported during the procedure. We present the case of a 58-year-old male diagnosed with left-sided trigeminal neuralgia involving mandibular division of trigeminal nerve (V3 division) with a Numerical Rating Scale of 9/10 at the time of presentation. As the patient was unresponsive to medical management, RFA of the V3 division of GG was performed with acceptable sensory and motor stimulation. Postablation, 1 ml of 1.0% Lidocaine injection with 2 mg injection dexamethasone was given. After the procedure, the patient complained of dizziness, left-sided hearing loss, and double vision on looking toward the left side. On examination, deviation of the angle of the mouth toward the right side, reduced blink reflex on the left side, and incomplete closure of the left eyelid were observed. Vitals were stable and there was no respiratory discomfort. The patient was reassured and monitored in the recovery room. Signs and symptoms were transient and the patient recovered completely after 45 min. Clinical findings were suggestive of the involvement of three cranial nerves: the abducens nerve, the facial nerve, and the vestibulocochlear nerve. Spillage of local anesthetic solution into adjacent cranial nerves surrounding the GG might be the causative mechanism for transient cranial nerve palsies in this case. [ABSTRACT FROM AUTHOR]

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Infection is a rare cause of panhypopituitarism and has not been reported in the context of Lemierre's syndrome. We present the case of a previously well 19-year-old man, who presented acutely unwell with meningitis and sepsis. Fusobacterium necrophorum was isolated from peripheral blood cultures and identified on cerebrospinal fluid with 16S rDNA Polymerase Chain Reaction (PCR). Imaging demonstrated internal jugular vein thrombosis with subsequent cavernous venous sinus thrombosis. Pituitary function tests were suggestive of panhypopituitarism. The patient was diagnosed with Lemierre's syndrome complicated by meningitis, cavernous sinus thrombosis, base of skull osteomyelitis, ischaemic stroke and panhypopituitarism. He was treated with 13 weeks of intravenous antibiotics followed by 3 weeks of oral amoxicillin, and anticoagulated with dalteparin then apixaban. His panhypopituitarism was managed with hydrocortisone, levothyroxine and desmopressin. [ABSTRACT FROM AUTHOR]

Abstract Background Neurosarcoidosis can have various neurological outcomes and presentations. It is an uncommon diagnosis, especially in young Caucasian males presenting with predominantly migraine headaches. Case presentation A Caucasian male in his 20s with no medical history presented with 1 month of intractable migraine headaches associated with left sided blurry vision, nausea and vomiting. He has also been having intermittent paresthesia’s in the left upper extremity. He reports lightheadedness when moving from sitting to standing and occasionally feels unsteady on his feet. He also endorses night sweats, generalized malaise, and fatigue. On admission, CT chest, abdomen, and pelvis showed diffuse lymphadenopathy above and below the diaphragm, as well as widespread pulmonary nodules. MR head and spine showed multiple and diffuse nodular leptomeningeal enhancements and enhancement foci along the cervical, thoracic, and lumbar spine. Lumbar puncture showed elevated total nucleated cells and protein. Surgical pathology from a right inguinal lymph node showed many scattered multinucleated giant cells and epithelioid histiocytes consistent with non-necrotizing granulomas seen in sarcoidosis. He was treated with high dose steroids with significant improvement in symptoms. Conclusions The diagnosis of neurosarcoidosis may be challenging, and the differential may include other infectious, neoplastic, and inflammatory conditions. Neurosarcoidosis may present in a young Caucasian male with a constellation of nonspecific neurological symptoms such as cranial nerve palsies, gait imbalance, paresthesia’s, and headaches, among other presentations. Neurosarcoidosis may present similarly to lymphoma with constitutional symptoms of night sweats, fatigue, as well as widespread lymphadenopathy. Histopathology may be useful in diagnosis. Neurosarcoidosis may initially respond well to steroid treatment.

Abstract Objective To identify the prevalence of cranial nerve (CN) palsy and its associated factors in malignant otitis externa (MOE). Methods In a retrospective study, records of MOE patients from 2011 to 2014 were reviewed. MOE and CN involvement were evaluated based on patient demographics, clinical, and paraclinical data. Results Overall, 119 MOE patients with a mean age of 65.9 ± 11.3 were included. 69.7% were male, and 63.0% had a history of diabetes. The most common symptoms and signs were otalgia (97.5%), otorrhea (44.5%), and ear canal erythema/edema (24.4%). Thirty‐three patients (27.7%) had CN involvement. The facial nerve was mostly involved (26.1%). Skull base osteomyelitis (SBO) was present in 59 patients. When excluding patients younger than 30 and older than 80, age decade was correlated with CN palsy. 66.9% of patients with CN palsy and 65.6% without CN palsy were male, which was significantly different. The following factors were not significantly different between patients with and without CN palsy: Comorbidities, signs and symptoms, diagnostic delay, erythrocyte sedimentation rate level, fasting blood sugar, hemoglobin A1c level, antifungal therapy, hospitalization duration, and SBO on imaging. Tinnitus was correlated with SBO evidence on imaging (specificity: 96.7%). Conclusion CN involvement occurs in about three out of 10 MOE patients. Male gender and advanced age may be related to a higher incidence rate of CN palsy. Tinnitus can be a specific indicator of SBO. These findings could help in better decision‐making for early interventions. Level of Evidence 4.

Purpose: To describe tumor response and cranial nerve function outcomes after administration of anti-PD-1 to patients with cutaneous squamous cell carcinoma (CSCC) with perineural spread to cranial nerves (CN) extending into the cavernous sinus. Methods: Electronic patient records from a single institution were queried for patients with CSCC of the head and neck causing diplopia (ICD-10 H53.2) who were treated with anti-PD-1. Data extracted included demographics, duration of anti-PD-1 therapy, immune-mediated adverse reactions, tumor response per adapted RECIST v1.1, and changes in CN function and symptoms (e.g., pain). All patients were prescribed cemiplimab 350 mg IV q3 weeks. Results: Four patients met inclusion criteria. They had varying degrees of pain and sensory deficits in branches of the trigeminal nerve (CN V). One, 2, 3 and 1 patients had baseline involvement of CN III, IV, VI and VII, respectively. MRI confirmed perineural cavernous sinus involvement in all patients. Duration of anti-PD-1 therapy ranged 15–60 weeks. All patients experienced an objective anti-tumor response to anti-PD-1; partial response n = 2, complete response n = 2. At a median follow-up of 22 months, responses were ongoing in all patients. All patients demonstrated improvement in ocular motility deficits and pain with resolution of symptoms in 3 and 1 patients, respectively. Conclusion: Administration of anti-PD-1 to patients with CSCC with perineural spread into the cavernous sinus can generate durable anti-tumor regressions and restore CN function, while sparing the morbidity associated with surgical resection and/or radiotherapy. Our findings add to emerging literature supporting this treatment approach for this patient population. [ABSTRACT FROM AUTHOR]

This study aimed to clarify the symptoms of pituitary or parasellar tumor onset with cranial nerve palsy (CNP) and to improve our knowledge of this rare symptom and its most appropriate treatment. Among 1281 patients with pituitary or parasellar tumors surgically treated from 2003 to 2020, 30 cases (2.34%; 15 men and 15 women; mean age: 55.6 years, range: 6–83 years) first presenting with CNP were reviewed to evaluate the neurological symptoms, histological diagnosis, interval from onset to surgery, and time before complete CNP recovery. Pathological diagnoses comprised 17 pituitary adenomas, including 10 pituitary apoplexies and 4 adrenocorticotropic hormone-positive adenomas, and 13 other tumors, including 3 chordomas, 2 xanthogranulomas, 2 malignant lymphomas, 2 metastatic tumors, 1 Rathke cleft cyst, 1 plasmacytoma, 1 craniopharyngioma, and 1 neuroendocrine carcinoma. The mechanisms causing CNP were pituitary apoplexy (n = 10), cranial nerve compression or involvement (n = 17), and inflammatory changes (n = 9). As the first manifestation, 20 (66.7%) patients presented with oculomotor nerve palsy, 2 (6.7%) with trochlear nerve palsy, and 13 (43.3%) with abducens nerve palsy. Full recovery of CNP was obtained in 25 patients (83.3%) after surgery alone and in 2 patients (6.7%) after adjuvant therapy. Early surgery provided no significant difference in full recovery rates although it reduced the time to reach full recovery. It is critical to determine the mechanisms of CNP and intervene surgically to improve symptoms, shorten the duration of the disorder, prevent relapses, and obtain the correct pathological diagnosis to select the proper adjuvant therapy. [ABSTRACT FROM AUTHOR]

The clinical manifestations of acute leukemia are diverse and can range from asymptomatic to life-threatening Complications.1 Cranial nerve palsies as a presenting feature of this disease is relatively rare. It can be attributed to leukemic infiltration of cranial nerves or the development of cranial nerve palsies secondary to intracranial complications such as subdural hematoma. Our patient presented with 4-month history of progressively worsening eye and visual disturbances. On examination, there was bilateral ptosis and proptosis. The right pupil was dilated and non-responsive to light with complete blindness. Left pupil had a sluggish response to light and had decreased visual acuity. There was 6th nerve palsy on left side and bilateral sensorineural hearing loss. Bone marrow biopsy showed Acute Lymphoblastic Leukemia. He was diagnosed with Acute Lymphoblastic Leukemia with brain (CNS) infiltration causing 2nd, 3rd, 6th and 8th cranial nerve palsies. [ABSTRACT FROM AUTHOR]

An Wen,1,2 Wen-Feng Cao,1,2 Shi-Min Liu,1,2 Yong-Liang Zhou,1,2 Zheng-Bing Xiang,1,2 Fan Hu,1,2 Ling-Feng Wu,1,2 Wen Cai,1,2 Er-Ling Leng3 1Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China; 2Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China; 3Department of Pediatrics, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of ChinaCorrespondence: Er-Ling Leng, Department of Pediatrics, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), No.92 Aiguo Road, Nanchang, 330006, People’s Republic of China, Tel +86791-8772-1401, Email wenan666@sina.comObjective: Tuberculous meningitis (TBM) is a common form of central nervous system (CNS) tuberculosis (TB). Cranial nerve palsy is a serious complication of TBM. Literature regarding this subject is still limited in China. This study evaluated the incidence of cranial nerve palsy in patients with TBM in South China, its association with the clinical forms of TB, and other patient characteristics.Methods: A retrospective chart review of patients with a diagnosis of TBM between January 2004 and December 2019 was conducted, and the demographic characteristics, clinical characteristics, and laboratory results of 114 patients were collected and followed up for 3 months. A multivariate logistic regression analysis model was used to explore the risk factors of cranial nerve palsy in patients with TBM.Results: A total of 114 patients were enrolled in this study. Cranial nerve palsy was observed in approximately 38 (33.3%) of TBM patients. Among them, 13 (28.3%) had optic nerve palsy, 24 (52.2%) had oculomotor nerve palsy, 5 (10.9%) had abducens nerve palsy, 2 (4.3%) had auditory nerve palsy, 1 (2.2%) had glossopharyngeal nerve palsy, and 1 (2.2%) had vagus nerve palsy. Using logistic regression analysis, focal neurological deficit, extracranial TB and cerebrospinal fluid (CSF) total white cell count (WCC) were shown to be risk factors for cranial nerve palsy.Conclusion: The prevalence rate of cranial nerve palsy was 33.3% in patients with TBM. Focal neurological deficits, extracranial TB and CSF total WCC are important predictors of cranial nerve palsy in patients with TBM.Keywords: tuberculous meningitis, tuberculosis, cranial nerve palsy, risk factors, prediction

Atlanto-occipital dislocation (AOD) is an injury to the upper cervical spine that occurs after trauma. This injury is associated with a high mortality rate. According to studies, 8%–31% of deaths caused by accidents are due to AOD. Due to the improvement in medical care and diagnosis, the rate of related mortality has decreased. Five patients with AOD were evaluated. Two cases had type 1, one case had type 2, and two other patients had type 3 AOD. All patients had weakness in the upper and lower limbs and underwent surgery to fix the occipitocervical junction. Other complications in patients were hydrocephalus, 6 nerve palsy, and cerebellar infarction. All patients improved in follow-up examinations. AOD damage is divided into four groups: anterior, vertical, posterior, and lateral. The most common type of AOD is type 1 and the most instability is type 2. There are neurological and vascular injuries due to pressure on regional components; vascular injuries are associated with high mortality rate. In most patients, their symptoms improved after surgery. AOD requires early diagnosis and immobilization of the cervical spine along with maintaining the airway to save the patient's life. It is necessary to consider AOD in cases with neurological deficits or loss of consciousness in the emergency unit because earlier diagnosis could cause a wonderful improvement of the patient's prognosis.

Yonathan Aliye Asfaw,1,2 Helen Huang,2,3 Muhammad Taimur,2,4 Ayush Anand,2,5 Sujan Poudel,2 Tulika Garg,2,6 Bethlehem Aliye Asfaw,1,2 Befekadu Molalegn Abebe,1,2 Hanieh Akbariromani,2,7 Gavrilo Lazovic,8 Wilson Cueva9 1Internal Medicine Department, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia; 2Department of Research & Academic Affairs, Larkin Community Hospital, South Miami, FL, USA; 3Internal Medicine Department, University of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; 4Internal Medicine Department, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan; 5Internal Medicine Department, B. P. Koirala Institute of Health Sciences, Dharan, Nepal; 6Internal Medicine Department, Government Medical College and Hospital, Chandigarh, India; 7Internal Medicine Department, Islamic Azad University, Tehran Medical Branch, Tehran, Iran; 8Department of Emergency Medicine, Larkin Community Hospital, South Miami, FL, USA; 9Department of Neurology, Larkin Community Hospital, South Miami, FL, USACorrespondence: Yonathan Aliye Asfaw, Internal Medicine Department, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia, Email dreaminglatee@gmail.comAbstract: Cerebral venous thrombosis (CVT) is a cerebrovascular disorder caused by complete or partial occlusion of the cerebral venous and sinus system. The etiology has been attributed to hypercoagulability and pro-thrombotic states, leading to raised intracranial pressures that often manifest as headaches and focal neurological deficits. However, the multifactorial nature of CVT can create a diagnostic conundrum for clinicians. We describe a unique case of a 16-year-old female who presented with convulsions, postictal confusion, and drowsiness followed by residual weakness of her extremities. She initially presented to the primary care center with headache, high-grade fever, and altered mental status and was empirically treated for pyogenic meningitis. The patient failed to improve with a week of antibiotics and was referred to the tertiary care center for urgent attention. On presentation, the patient developed VI and VII cranial nerve palsy. Subsequently, MRI images showed filling defects in the superior sagittal, right transverse, and sigmoid sinuses with right parietal gyral T1 hyperintensity and T2 hypo-intensity. She was diagnosed with septic CVT based on sinus venous thrombosis and venous infarction, probably secondary to meningococcal pneumonia. It can be challenging to distinguish between both conditions as their presentations overlap. Moreover, cranial nerve palsy is an infrequent manifestation of CVT, with unclear pathogenesis. We highlight the role of neuro-imaging in the early detection of CVT and bring to light the unfamiliar symptoms and a more varied clinical spectrum that may hinder the diagnosis in a limited-resource setting. Future research should be explicitly modeled to improve the diagnostic efficiency of CVT and improve outcomes in younger patient populations.Keywords: cerebral venous thrombosis, meningitis, cranial nerve palsy, systemic infection, neuro-imaging, case report

Background: Neurosarcoidosis can have various neurological outcomes and presentations. It is an uncommon diagnosis, especially in young Caucasian males presenting with predominantly migraine headaches. Case presentation: A Caucasian male in his 20s with no medical history presented with 1 month of intractable migraine headaches associated with left sided blurry vision, nausea and vomiting. He has also been having intermittent paresthesia's in the left upper extremity. He reports lightheadedness when moving from sitting to standing and occasionally feels unsteady on his feet. He also endorses night sweats, generalized malaise, and fatigue. On admission, CT chest, abdomen, and pelvis showed diffuse lymphadenopathy above and below the diaphragm, as well as widespread pulmonary nodules. MR head and spine showed multiple and diffuse nodular leptomeningeal enhancements and enhancement foci along the cervical, thoracic, and lumbar spine. Lumbar puncture showed elevated total nucleated cells and protein. Surgical pathology from a right inguinal lymph node showed many scattered multinucleated giant cells and epithelioid histiocytes consistent with non-necrotizing granulomas seen in sarcoidosis. He was treated with high dose steroids with significant improvement in symptoms. Conclusions: The diagnosis of neurosarcoidosis may be challenging, and the differential may include other infectious, neoplastic, and inflammatory conditions. Neurosarcoidosis may present in a young Caucasian male with a constellation of nonspecific neurological symptoms such as cranial nerve palsies, gait imbalance, paresthesia's, and headaches, among other presentations. Neurosarcoidosis may present similarly to lymphoma with constitutional symptoms of night sweats, fatigue, as well as widespread lymphadenopathy. Histopathology may be useful in diagnosis. Neurosarcoidosis may initially respond well to steroid treatment. [ABSTRACT FROM AUTHOR]

Objective: To identify the prevalence of cranial nerve (CN) palsy and its associated factors in malignant otitis externa (MOE). Methods: In a retrospective study, records of MOE patients from 2011 to 2014 were reviewed. MOE and CN involvement were evaluated based on patient demographics, clinical, and paraclinical data. Results: Overall, 119 MOE patients with a mean age of 65.9 ± 11.3 were included. 69.7% were male, and 63.0% had a history of diabetes. The most common symptoms and signs were otalgia (97.5%), otorrhea (44.5%), and ear canal erythema/edema (24.4%). Thirty‐three patients (27.7%) had CN involvement. The facial nerve was mostly involved (26.1%). Skull base osteomyelitis (SBO) was present in 59 patients. When excluding patients younger than 30 and older than 80, age decade was correlated with CN palsy. 66.9% of patients with CN palsy and 65.6% without CN palsy were male, which was significantly different. The following factors were not significantly different between patients with and without CN palsy: Comorbidities, signs and symptoms, diagnostic delay, erythrocyte sedimentation rate level, fasting blood sugar, hemoglobin A1c level, antifungal therapy, hospitalization duration, and SBO on imaging. Tinnitus was correlated with SBO evidence on imaging (specificity: 96.7%). Conclusion: CN involvement occurs in about three out of 10 MOE patients. Male gender and advanced age may be related to a higher incidence rate of CN palsy. Tinnitus can be a specific indicator of SBO. These findings could help in better decision‐making for early interventions. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Introduction : The study was done to find out the ocular manifestation in patients with extrapulmonary tuberculosis visiting a tertiary eye centre. Methods: A hospital based descriptive observational study was done among newly diagnosed extrapulmonary tuberculosis cases after approval from the institutional review board. After a detailed ocular evaluation, findings including patient demographics, presenting complaints, best corrected visual acuity, colour vision, contrast sensitivity, Goldman visual field and Optical Coherence tomography Retinal nerve fibre layer analysis of the optic nerve head were recorded in a semi-structured proforma. Data were expressed in frequency and percentage. Results: Out of 50 eyes of 25 patients included in the study, the mean age was 26.92±14.2 years (11-73 years). Sixty four percent were female. Two cases had ocular findings at the time of diagnosis. One case of tuberculous lymphadenitis had phlyctenular conjunctivitis and one case of tubercular meningitis had diplopia with right lateral rectus muscle paresis secondary to raised intracranial pressure. All the patients had best corrected visual acuity better than 6/12 at presentation. Color vision was normal in 72% cases in both eyes. Goldman visual field done at presentation were normal in both eyes in 88% cases while retinal nerve fibre layer thickness and contrast sensitivity were normal in all cases. Conclusion: The prevalence of ocular findings in patients with extrapulmonary tuberculosis was 8% in this study. Ocular examination is important in cases with extrapulmonary tuberculosis since a significant number of cases have ocular findings.