OBJECTIVE

To discuss the clinical presentation and management of idiopathic hypertrophic pachymeningitis that presented with multiple cranial neuropathies.

This is a case report.

A 37-year-old female presented with right-sided headache and ipsilateral cranial nerve (CN) I, II, III, IV, and V deficits which improved with nonsteroidal anti-inflammatory drugs (NSAIDs). Six months later she developed bilateral blurring of vision with pain on eye movement, which progressed to severe bilateral affectation that prompted admission and treatment with high-dose methylprednisolone therapy followed by prolonged oral steroid treatment which was gradually tapered. Recurrence was treated with oral steroids and azathioprine. Diagnostic modalities included an initial cranial contrast computed tomography (CT) scan which was inconclusive; contrast magnetic resonance imaging (MRI) clinched the diagnosis, as well as demonstrated thickening of the optic nerve perineurium. Visual field analysis 30-2 as well as optic nerve head optical coherence tomography (OCT) were used to support the diagnosis and document optic nerve affectation. Biologic testing was used to rule out tuberculosis, syphilis, fungal infection, granulomatosis with polyangiitis, polyarteritis nodosa, and rheumatoid arthritis. The patient had complete vision recovery in the left eye but only partial vision recovery in the right eye.

Pachymeningitis should be a diagnostic consideration in patients with headache and multiple cranial neuropathies. Clinicians should always perform independent evaluation of diagnostic modalities with the patient’s clinical presentation in mind. Pachymeningitis can involve the perineurium through contiguous spread of the lesion and present as optic perineuritis as well, with more insidious progression and lasting deficits than isolated optic perineuritis.

This article reports a case of multiple cranial nerve injury after gamma knife radiosurgery treated with acupuncture and moxibustion combined with rehabilitation therapy. The patient presented with weakness of facial and tongue muscles, hoarseness, choking on water, and swallowing difficulties. The syndrome was attributed to qi and blood deficiency, and blood stasis obstructing the collaterals. The treatment principle focused on replenishing qi and blood, promoting blood circulation and unblocking collaterals. Yintang (GV24⁺), Lianquan (CV23), Qihai (CV6), Guanyuan (CV4), and Cuanzhu (BL2), Yangbai (GB14), Jingming (BL1), Sizhukong (TE23), Yingxiang (LI20), Sibai (ST2), Juliao (ST3), Quanliao (SI18), Dicang (ST4), Jiache (ST6), Xiaguan (ST7), Taiyang (EX-HN5) on the affected side, bilateral Jinjin (EX-HN12), Yuye (EX-HN13), Hegu (LI4), Zusanli (ST36), Sanyinjiao (SP6), Tianshu (ST25) were selected. Among these, bilateral Jinjin (EX-HN12) and Yuye (EX-HN13) were treated with pricking, Dicang (ST4) and Jiache (ST6) on the affected side were connected to an electroacupuncture device, and warming acupuncture was applied at Guanyuan (CV4). Rehabilitation therapy and electromyographic biofeedback were also incorporated. The treatments were given 2-3 times a week. After 18 months of intermittent treatment, the patient reported significant improvement, House Brackmann (H-B) facial nerve function grade was Ⅳ, and Sunnybrook facial nerve rating scale score was 53 points. After 2-month of follow-up, the patient reported normal swallowing ability and restored social engagement.
Humans ; Acupuncture Points ; Acupuncture Therapy ; Cranial Nerve Diseases/therapy*

PURPOSE: To understand the ophthalmic clinical features and outcomes of facial nerve palsy patients who were referred to an ophthalmic clinic for various conditions like Bell's palsy, trauma, and brain tumor. METHODS: A retrospective study was conducted of 34 eyes from 31 facial nerve palsy patients who visited a clinic between August 2007 and July 2017. The clinical signs, management, and prognosis were analyzed. RESULTS: The average disease period was 51.1 ± 20.6 months, and the average follow-up duration was 24.0 ± 37.5 months. The causes of facial palsy were as follows: Bell's palsy, 13 cases; trauma, six cases; brain tumor, five cases; and cerebrovascular disease, four cases. The clinical signs were as follows: lagophthalmos, 24 eyes; corneal epithelial defect, 20 eyes; conjunctival injection, 19 eyes; ptosis, 15 eyes; and tearing, 12 eyes. Paralytic strabismus was found in seven eyes of patients with another cranial nerve palsy (including the third, fifth, or sixth cranial nerve). Conservative treatments (like ophthalmic ointment or eyelid taping) were conducted along with invasive procedures (like levator resection, tarsorrhaphy, or botulinum neurotoxin type A injection) in 17 eyes (50.0%). Over 60% of the patients with symptomatic improvement were treated using invasive treatment. At the time of last following, signs had improved in 70.8% of patients with lagophthalmos, 90% with corneal epithelium defect, 58.3% with tearing, and 72.7% with ptosis. The rate of improvement for all signs was high in patients suffering from facial nerve palsy without combined cranial nerve palsy. CONCLUSIONS: The ophthalmic clinical features of facial nerve palsy were mainly corneal lesion and eyelid malposition, and their clinical course improved after invasive procedures. When palsy of the third, fifth, or sixty cranial nerve was involved, the prognosis and ophthalmic signs were worse than in cases of simple facial palsy. Understanding these differences will help the ophthalmologist take care of patients with facial nerve palsy.
Bell Palsy ; Brain Neoplasms ; Cerebrovascular Disorders ; Cranial Nerve Diseases ; Cranial Nerves ; Epithelium, Corneal ; Eyelids ; Facial Nerve ; Facial Paralysis ; Follow-Up Studies ; Humans ; Paralysis ; Prognosis ; Retrospective Studies ; Strabismus ; Tears

BACKGROUND: The laryngeal mask airway (LMAⓇ) Protector™ (Teleflex Medical Co., Ireland) is the latest innovation in the second generation of LMA devices. One distinguishing feature of this device is its integrated, color-coded cuff pressure indicator (Cuff ™ technology) which enables continuous cuff pressure monitoring and allows adjustments when necessary; this ensures patient safety due to better monitoring.CASE: We report a case of postoperative unilateral hypoglossal nerve palsy after uncomplicated use of the LMA Protector. To the best of our knowledge, this could be the second reported case.CONCLUSIONS: This case demonstrates that anesthetists need to routinely measure cuff pressure and that the Cuff Pilot™ technology is not a panacea for potential cranial nerve injury after airway manipulation.
Cranial Nerve Injuries ; Hypoglossal Nerve Diseases ; Hypoglossal Nerve ; Laryngeal Masks ; Patient Safety

No abstract available.
Cranial Nerve Diseases ; Cranial Nerves ; Hoarseness ; Vertebrobasilar Insufficiency ; Vocal Cord Paralysis

PURPOSE: To report a case of pituitary apoplexy presenting as isolated bilateral oculomotor nerve palsy. CASE SUMMARY: A 46-year-old male presented with bilateral ptosis and acute severe headaches for 6 days. He underwent head surgery and bilateral vitrectomy 12 years prior to his visit because of ocular and head trauma. He mentioned that previous visual acuities in both eyes were not good. The initial corrected visual acuity was finger counting in the right eye and 20/500 in the left eye. Ocular motility testing revealed the limitation of adduction, supraduction, and infraduction with complete bilateral ptosis in both eyes, and his left pupil was dilated. He was diagnosed with an isolated bilateral oculomotor nerve palsy. Magnetic resonance imaging indicated pituitary gland hemorrhage with a tumor, which was suspicious of pituitary apoplexy. The patient was treated intravenous with 1.0 g methylprednisolone to prevent the corticotropic deficiency. In addition, he underwent surgical decompression using a navigation-guided transsphenoidal approach and aspiration biopsy. He was confirmed with pituitary adenoma using a pathological examination. The patient's ocular movements began to dramatically improve by the third day postoperatively. At 4 months postoperative follow-up, his ocular movement and double vision were completely recovered. CONCLUSIONS: This was a rare case of pituitary apoplexy with bilateral isolated oculomotor nerve palsy, which was the first report in the Republic of Korea. A full recovery was achieved after early surgical treatment.
Biopsy, Needle ; Cranial Nerve Diseases ; Craniocerebral Trauma ; Decompression, Surgical ; Diplopia ; Fingers ; Follow-Up Studies ; Head ; Headache ; Hemorrhage ; Humans ; Magnetic Resonance Imaging ; Male ; Methylprednisolone ; Middle Aged ; Oculomotor Nerve Diseases ; Oculomotor Nerve ; Pituitary Apoplexy ; Pituitary Gland ; Pituitary Neoplasms ; Pupil ; Republic of Korea ; Visual Acuity ; Vitrectomy

PURPOSE: To investigate the types and clinical features of neurological diseases after head trauma. METHODS: From March 2010 to December 2018, a total of 177 patients were enrolled in this study. We retrospectively reviewed the clinical features of neurological ophthalmic diagnoses and frequencies, the types of head injuries, and the prognoses. RESULTS: Cranial nerve palsy was the most common (n = 63, 35.6%), followed by traumatic optic neuropathy (n = 45, 25.4%), followed by optic disc deficiency, ipsilateral visual field defect, Nystagmus, skewing, ocular muscle paralysis between nuclei, and Terson syndrome. Neuro-ophthalmic deficits occurred in relatively strong traumas accompanied by intracranial hemorrhage or skull fracture. However, convergence insufficiency and decompensated phoria occurred in relatively weak trauma such as concussion. The prognoses of the diseases were poor (p < 0.05) for traumatic optic neuropathies and visual field defects. The prognoses of neurological diseases were poor if accompanied by intracranial hemorrhages or skull fractures (p < 0.05). CONCLUSIONS: After head trauma, various neuro-ophthalmic diseases can occur. The prognosis may differ depending on the type of the disease, and the strength of the trauma may affect the prognosis.
Cranial Nerve Diseases ; Craniocerebral Trauma ; Diagnosis ; Head ; Humans ; Intracranial Hemorrhages ; Ocular Motility Disorders ; Optic Nerve Injuries ; Paralysis ; Prognosis ; Retrospective Studies ; Skull Fractures ; Strabismus ; Visual Fields

Upon review, it is noted that recurrent painful ophthalmoplegic neuropathy (RPON) is a rare neurological syndrome characterized by recurrent unilateral headaches and painful ophthalmoplegia of the ipsilateral oculomotor nerve. As seen on brain MRI, thickening and enhancement of the oculomotor cranial nerve can be observed in these cases. We experienced a case of RPON in an adult patient who showed thickening and enhancement of the oculomotor nerve on gadolinium-enhanced 3D-FLAIR image. The authors report a case of RPON with a review of the literature.
Adult ; Brain ; Cranial Nerves ; Headache ; Humans ; Magnetic Resonance Imaging ; Oculomotor Nerve ; Oculomotor Nerve Diseases ; Ophthalmoplegia ; Paralysis

BACKGROUND: Herpes zoster of the head and neck commonly presents with Ramsay Hunt syndrome. However, vesicular eruptions may occur on the pharyngeal or laryngeal area with multiple lower cranial-nerve (CN) palsy. CASE REPORT: We report on the case of a 54-year-old man with herpes zoster of the pharynx and larynx with multiple CN palsy and persistent hiccups. He initially developed progressive dysphagia, hoarseness, and persistent hiccups (CN IX and X). After admission, Dizziness, hearing impairment, and peripheral facial palsy (CN VII and VIII) were complicated. The results of a polymerase chain reaction test of saliva and vesicular fluid from the ear and throat were strongly positive for varicella zoster virus. The progression of CN palsy was in an ascending sequence. CONCLUSION: We suggest that the sequence of CN palsy may be either ascending or descending, depending on the initial site of involvement.
Cranial Nerve Diseases ; Cranial Nerves ; Deglutition Disorders ; Dizziness ; Ear ; Facial Paralysis ; Head ; Hearing Loss ; Herpes Zoster Oticus ; Herpes Zoster ; Herpesvirus 3, Human ; Hiccup ; Hoarseness ; Humans ; Laryngitis ; Larynx ; Middle Aged ; Neck ; Paralysis ; Pharynx ; Polymerase Chain Reaction ; Saliva

We present our experience on the hypofractionated Gamma Knife radiosurgery (FGKS) for large skull base meningioma as an initial treatment. We retrospectively reviewed 23 patients with large skull base meningioma ≥10 cm³ who underwent FGKS as the initial treatment option. The mean volume of tumors prior to radiosurgery was 21.2±15.63 cm³ (range, 10.09~71.42). The median total margin dose and marginal dose per fraction were 18 Gy (range, 15~20) and 6 Gy (range, 5~6), respectively. Patients underwent three or four fractionations in consecutive days with the same Leksell® frame. The mean follow-up duration was 38 months (range, 17~78). There was no mortality. At the last follow-up, the tumor volume was stationary in 15 patients (65.2%) and had decreased in 8 patients (34.8%). Six patients who had cranial neuropathy at the time of FGKS showed improvement at the last clinical follow-up. Following FGKS, 4 patients (17%) had new cranial neuropathy. The trigeminal neuropathy was the most common and all were transient. The mean Karnofsky Performance Status score at pre-FGKS and the last clinical follow-up was 97.0±10.4 points (median, 100) and 98.6±6.9 (median, 100) points, respectively. FGKS has showed satisfactory tumor control with functional preservation for large skull base meningiomas. Further prospective studies of large cohorts with long term follow-up are required to clarify the efficacy in the tumor control and functional outcome as well as radiation toxicity.
Cohort Studies ; Cranial Nerve Diseases ; Dose Hypofractionation ; Follow-Up Studies ; Humans ; Karnofsky Performance Status ; Meningioma* ; Mortality ; Prospective Studies ; Radiosurgery* ; Retrospective Studies ; Skull Base* ; Skull* ; Trigeminal Nerve Diseases ; Tumor Burden