Intermittent abducens nerve palsy caused by a microvascular compression syndrome
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LETTER TO THE EDITOR
Intermittent abducens nerve palsy caused by a microvascular compression syndrome Caroline Schotte1 · Jan Wuyts2 · Valérie Verhelle3 · Sofie Van Cauter4 Received: 11 April 2019 / Accepted: 19 March 2020 © Belgian Neurological Society 2020
Keywords Abducens nerve · Microvascular compression syndrome · Microvascular decompression · Diplopia · Anterior inferior cerebellar artery
Introduction We describe the case of a patient with an intermittent horizontal diplopia caused by a neurovascular conflict of the anterior inferior cerebellar artery (AICA) and the root entry zone of the abducens nerve. The patient was successfully treated with a combination of microvascular decompression and strabismus correction surgery.
Case report This 53-year-old Caucasian woman presented with a progressive, intermittent binocular horizontal diplopia since several months. She had a past medical history of failed back surgery, failed neurostimulator placement, systemic lupus erythematosus (SLE) with joint, eye and skin lesions, hearing loss due to hydroxychoroquine treatment and a lung hamartoma surgically treated with a superior right-sided lobectomy. For these conditions, she was being treated with azathioprine, buprenorphine and morfine. At the time of this presentation, she had no manifestations of active SLE. At clinical examination, a horizontal diplopia with gaze deviation to the left side was noted. Additional ophthalmological * Caroline Schotte [email protected] 1
exam reported a slight esophoria and esotropia, a subtle abducens nerve palsy was suspected. MRI of the brain was performed and showed direct contact between the left AICA and the root exit zone (REZ) of the left abducens nerve, suggesting vascular compression (Fig. 1). Furthermore, there were some punctuate white matter lesions, compatible with chronic ischemia Fazekas grade 1. No other abnormalities were present. Conservative treatment with prism lenses and carbamazepine had no effect on the diplopia. Because of worsening diplopia, the patient agreed to undergo a microvascular decompression (MVD). The surgery was performed more than 1 year after the onset of symptoms. During surgery, a very narrow relationship between the sixth nerve and the AICA, as well as the basilar artery was observed at the root entry zone. Two pieces of Teflon felt were positioned in between the nerve and the arteries (Fig. 2). The postoperative course was uneventful. At discharge, the diplopia was unchanged. Six months after the MVD, the diplopia had not resolved, although it had evolved to a less severe constant horizontal diplopia instead of being intermittent. A strabismus correcting surgery was performed by recessing both medial rectus muscles with 5 mm and with a loop on the left side. After this procedure, the symptoms resolved completely.
Department of Neurology, AZ Monica, 2100 Antwerp, Belgium
Discussion
2
Department of Neurosurgery, Ziekenhuizen Oost Limburg, 3600 Genk, Belgium
3
Department of Ophthalmology, Ziekenhuizen Oost Limburg, 3
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