A case report of unilateral cervical lymphadenopathy and multiple cranial neuropathies following mRNA-COVID-19 vaccination.

BACKGROUND: We report a rare case of ipsilateral multiple cranial neuropathy and ipsilateral lymphadenopathy following mRNA-COVID-19 vaccination. CASE PRESENTATION: A 41-year-old male visited our emergency room complaining of dysphagia and hoarseness that started a week after receiving COVID19 mRNA vaccination (in his right arm). During his hospitalization, he also complained of right side hearing loss and diplopia. Neurological examination depicted a right IV nerve palsy, ipsilateral facial paresthesia and peripheral facial paresis. Otorinolaryngological examination revealed right vocal cord paralysis. A brain magnetic resonance imaging showed enhancement of the right VII and VIII cranial nerves in the auditory canal. The lumbar puncture revealed increased protein concentration and lymphocytic pleocytosis in the cerebrospinal fluid (CSF). Additionally, a neck computed tomography (CT) scan showed a swollen right supraclavicular lymph node. We hypothesize that the ipsilateral cranial neuropathies of IV, VI, VII, VIII and X, associated with cervical lymphadenopathy, was possible caused by a post-vaccination immune-mediated reaction. The patient was treated with a 5-day course of intravenous methylprednisolone (1000 mg/day), and a gradual improvement was observed. CONCLUSIONS: Similarly, to other vaccines, it is possibly that also mRNA vaccines may act as triggers of non-specific autoimmune neurological syndromes.

SLE pachymeningitis and multiple cranial nerve palsies: a case report and review of the literature.

Hypertrophic pachymeningitis (HP) is a relatively uncommon disease associated with focal or diffuse thickening of the dura mater secondary to underlying chronic inflammation. The link between systemic lupus erythematosus (SLE) and hypertrophic pachymeningitis (HP) is extremely rare, with only six other cases reported in the literature. We, however, report the first case of SLE pachymeningitis presenting with multiple cranial nerve palsies. The patient showed good response to steroids and cyclophosphamide therapy. One should maintain a high index of suspicion to make the diagnosis in patients with SLE presenting with neurological dysfunction. Prompt therapy prevents long-term neurological sequelae.

Safety and efficacy of thermal ablation (radiofrequency and laser): should we treat all types of thyroid nodules? †.

Background: Thermal ablation is a minimally invasive technique that is gradually acknowledged as an effective alternative to surgery to treat thyroid nodules. Two main techniques have been described: radiofrequency (RFA) and laser ablation. Objective: To evaluate the safety and efficacy of the two main techniques (RFA and laser ablation) for the treatment of benign thyroid nodules. Patients: This bicentric retrospective study included 166 consecutive patients, who received clinical, biological and ultrasound evaluations for thyroid nodules, from October 2013 to November 2017. Methods: One of the two techniques was proposed if a nodule was proven to be benign after fine needle aspiration cytology or micro-biopsy. Adverse events and outcomes (symptoms, nodule reduction) were assessed at 6 weeks and 6, 12, and 18 months after treatment. Results: One hundred and eighty-nine nodules (mean size 17.5 ± 16.9 mL, 86.1% palpable) were treated by RFA (n = 108 (57.1%)) or laser ablation (n = 81 (42.9%)) in 166 patients (80.1% women, mean age 51.7 years). Two cases of transient recurrent laryngeal nerve palsy, one hematoma, and two successfully drained abscesses (5/166 = 3%) were observed. Clinical symptoms improved significantly in the two groups (anterior cervical discomfort -83.6%, esthetic complaints -84.9% and dysphagia -86.4%). Nodule volume (mL) decreased significantly (baseline vs. 18 months) from 20.4 ± 18.6 to 5.8 ± 6.6 (-75%) in the RFA, and from 13.6 ± 13.3 to 3.4 ± 4.1 (-83.9%) in the laser ablation groups. Conclusions: Transient but potentially serious adverse events were reported in 3% of patients. A significant volumetric reduction was achieved with both techniques, regardless of nodule's characteristics, at 18 months.

[Three-month rehabilitation of a patient with the III, IV and VI cranial nerve damage caused by a neurosurgery of the left internal carotid artery aneurysm].

OBJECTIVE: Introduction: Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. Third nerve damage weakens the muscles innervated by the nerve . Also adversely affect the fourth and sixth nerve , causing impairment of their activity. Rehabilitation third nerve palsy is rarely described in the available literature . The whole process is very difficult , but the effects of physiotherapy is very beneficial for the patient. The aim:The assessment of the influence of the outpatient rehabilitation on the patient's condition after a three-month treatment and the use of physical therapy. PATIENTS AND METHODS: Material and methods:Case studies of the 38-yerar-old patient after having operated a big aneurism of the left ICA, which was clipped. After the procedure, the III, IV and VI cranial nerves were deeply impaired and the amnesic aphasia occurred. The patient started the rehabilitation a month after the incident. To assess the process of rehabilitation, the own movement examination of the eyeball was implemented. Active and passive exercises, Tigger Point therapy, kinesiotaping, laser and electrostimulation were inserted. RESULTS: Results: The significant improvement of the eyeball movement has been proved on the basis of the same own examination. A physiotherapy has had a positive influence on the speech disorder, namely amnesic aphasia, and after the month of the rehabilitation it has been completely removed. The positive influence of the rehabilitation, which has been pointed out, is clinically essential. CONCLUSION: Conclusions: Obtained results have not been described in literature yet, that is why it is essential to widen further research and emphasise the importance of the rehabilitation, which is rarely implemented in an intense way in such medical conditions.

[Effects of Endovascular Treatment on Cranial Nerve Palsy due to Unruptured Intracranial Aneurysms].

This study aimed to assess the effects of endovascular treatment on cranial nerve palsy due to unruptured intracranial aneurysms. Endovascular coiling was performed in 203 patients with intracranial aneurysms between April 2002 and March 2012 in our hospital. Of these patients, 8(3.9%)presented with cranial nerve palsy due to unruptured intracranial aneurysms. Cranial nerve palsy involved the oculomotor nerve in 8 patients and the optic nerve in 2 patients. Two patients had both optic nerve and oculomotor nerve dysfunction. Patients with incomplete oculomotor nerve palsy at admission were more likely to have full recovery after coiling. Optic nerve dysfunction did not improve after coiling. Incomplete oculomotor nerve palsy, early treatment(≤15 days), and small aneurysms(≤10 mm)were likely to be associated with complete recovery after coiling. This study indicates that endovascular coiling may resolve cranial nerve palsy due to unruptured intracranial aneurysms in patients who have incomplete oculomotor nerve palsy due to small aneurysms and are treated as early as possible after symptom onset.

Surgical neurolysis for the treatment of neuropathic pain in 2 postmenopausal women with mandibular necrosis resulting from oral bisphosphonates.

We analyze the use of surgical neurolysis for the treatment of neuropathic pain of the inferior alveolar nerve. For that, 3 surgical neurolysis were performed on 2 postmenopausal women experiencing neuropathic pain of the inferior alveolar nerve due to mandibular necrosis resulting from treatment with oral bisphosphonates. Both patients showed sensory impairment of the inferior alveolar nerve. We obtained complete control of neuropathic pain after 6 months of the patients' evolution, preserving the function of the lingual nerve in all 3 neurolysis, without causing any impact as regards to the sensitive situation before treatment. Surgical neurolysis of the inferior alveolar nerve may be considered as the choice therapeutic technique to treat neuropathic pain of this nerve when there is a sensory impairment in patients showing mandibular necrosis resulting from bisphosphonates.

[Intrapituitary adenoma metastasis from lung cancer with progressive cranial nerve palsies: a case report and literature review].

We report a rare case of metastasis to a preexisting pituitary adenoma. An 80-year-old man with a history of pituitary adenoma and lung cancer presented with recent onset of bilateral visual impairment, oculomotor nerve palsies, and severe headache. A CT scan revealed a pituitary tumor expanding into the suprasellar region and infiltrating the bilateral cavernous sinuses. We performed transsphenoidal surgery and diagnosed the tumor as lung cancer metastasis to the pituitary adenoma. After the surgery, visual impairment and severe headache were resolved, and the patient underwent radiation therapy for the residual tumor. To the best of our knowledge, 20 cases of metastases to pituitary adenomas have been reported in the literature. Clinical features of metastasis to a pituitary adenoma are different from those of metastasis to normal pituitary gland. In the case of a pituitary lesion with acute aggravation, one should be aware of the possibility of metastasis to preexisting pituitary adenomas.

Successful endovascular management of brain aneurysms presenting with mass effect and cranial nerve palsy.

Aneurysms presented with mass effect are traditionally treated by surgical clipping to decompress their mass effect. The aim of this work is to discuss the efficiency of endovascular techniques in treating 47 patients with variable sizes of intracranial aneurysms presented with mass effect and/or cranial nerve palsy. There were 47 patients with 47 unruptured aneurysms. Group I includes 28 giant aneurysms; all are treated by parent vessel occlusion with or without intra-aneurysmal occlusion depending on anatomical locations. Group II includes 19 small and large aneurysms; all are treated by selective endosaccular occlusion with coils. Clinical presentations were ocular cranial nerve dysfunction (82.9%), optic nerve or chiasmatic dysfunction (21.2%), brain stem compression (8.5%), embolic (6%), epistaksis (4%), proptosis (2%), and bleeding per ear (2%). Out of 47 patients, symptoms were resolved in 31 cases (66%), improved in 10 cases (21%), and unchanged in six cases (13%). Out of 28 giant aneurysms, symptoms were resolved in 19 (68%), improved in four (14%), and unchanged in five (18%). Only four (14%) patients out of the 19 giant aneurysms with complete symptoms resolution showed significant mass reduction in MRI. Out of 19 non-giant aneurysm cases treated by selective endovascular occlusion with coils, symptoms were resolved in 12 cases (63%), improved in six (32%), and unchanged in one (5%). No complications from the treatment were observed. The longer the duration of symptoms before endovascular treatment is, the longer the duration till improvement or resolution postoperative in both groups. Recovery of aneurysm-induced mass effect occurs in most patients both after parent vessel occlusion and after selective coiling, and is comparable to results after surgical clipping. The improvement starts independent of aneurysmal shrinkage in postoperative MRI follow-ups. The arrest of pulsations and partial shrinkage within the aneurysms after endovascular treatment may be the logical reason behind neurological recovery.

Cranial nerve palsies in childhood parameningeal rhabdomyosarcoma.

BACKGROUND: Children with parameningeal rhabdomyosarcoma (PM RMS) and cranial nerve palsy (CNP) are at risk for permanent neurologic dysfunction. Clinicians often consider the use of emergent therapies such as expedited radiation and/or corticosteroids; however, there is a paucity of information describing the natural history of CNP in PM RMS. We sought to describe the clinical features of patients with PM RMS plus associated CNP and to evaluate the patient, disease, and treatment-related factors that impacted neurologic recovery. METHODS: We conducted a retrospective review of PM RMS cases treated at the Hospital for Sick Children between 1985 and 2010. RESULTS: Thirty-five children were treated for PM RMS, 19 (54%) of whom presented with CNP. Children with CNP were nine times more likely to have other high-risk features (cranial base bony erosion and/or intracranial extension) at the time of presentation than children without CNP (OR 9.6, 95% CI 1.69, 54.79, P = 0.013). In addition to commencing chemotherapy, 13 patients (68%) received expedited RT and corticosteroids, four (21%) corticosteroids alone, and two (11%) received only standard chemotherapy and RT. At last follow up of the 11 survivors, neurologic recovery was complete in five (45%), partial in five (45%), and absent in one (9%). CONCLUSIONS: In our cohort, recovery of PM RMS associated CNP was often incomplete despite multi-modal therapy. A larger cohort of patients is required to determine the utility of emergent initiation of radiation or corticosteroids. This study will facilitate the counseling of future families on the long-term neurologic recovery CNP in PM RMS.

Is Hypertrophic Pachymeningitis Really Idiopathic?

Background: Hypertrophic pachymeningitis (HPM) is a unique disorder characterized by thickening and fibrosis of the dura mater. Clinically it presents with headache, cranial nerve palsies, and other focal neurological deficits. Two forms exist, one is primary, where all other causes have been excluded and the other is secondary where an identifiable cause exists. It is important to recognize these secondary causes as treatment depends on the etiology. Objective: To elucidate the various characteristics of HPM. To delineate clinical-radiological features that help differentiate secondary from primary causes and to understand treatment response and disease outcomes of HPM. Methods: This retrospective observational study included 33 patients who presented with radiological diagnosis of HPM from January 2014 to July 2019. Spontaneous intracranial hypotension patients were excluded. All patients were extensively evaluated for secondary causes and treatment outcomes were analyzed on follow-up. Results and Conclusions: Secondary causes of HPM were present in 48% cases. The clue for primary causes is an associated Tolosa-Hunt syndrome. Secondary causes in our series are immunological, infection, and malignancy. Clues to differentiate primary from these secondary causes are clinical like myelopathy, seizures, poor response to immunosuppression; radiological like hypertrophic cranial nerves, infarcts, bony erosion, and leptomeningeal involvement. There are case reports in literature but large Indian studies are lacking. This manuscript presents a large cohort of cases with HPM, which helps differentiate primary from secondary causes, as management and prognosis depend on etiology. An algorithm depicting the approach to the management of HPM has been presented.

Rapid Recovery of Cranial Nerve Deficits After Anterior Petrosal (Kawase) Approach for Medically Refractory Petrous Apicitis.

BACKGROUND: The mainstay treatment for petrous apicitis (Gradenigo's syndrome) is medical management with antibiotics, steroids, and placement of pressure equalization tubes. The role for surgery is limited as second-line treatment if conservative methods have failed. CASE DESCRIPTION: We report 2 cases of medically refractory petrous apicitis presenting with progressive cranial neuropathies who underwent petrous apex resection and debridement via an anterior petrosal (Kawase) approach. Both patients had improvement of their preoperative cranial nerve deficits within 24-48 hours of surgery, that previously did not improve after 2 weeks of medical management. CONCLUSIONS: To our knowledge, the use of the Kawase approach for petrous apicitis has not been previously reported. In addition, we postulate that surgical intervention can potentially result in quicker recovery of preexisting cranial nerve deficits in medically refractory petrous apicitis. This raises the potential role of earlier surgical intervention.

[Multiple cerebral hemorrhages due to varicella-zoster virus vasculopathy presenting as cranial nerve palsy].

A 72-year-old man was admitted to our hospital because of right facial muscle weakness and diplopia. He had been treated for aplastic anemia with cyclosporin for 2 years. Thirteen days before admission, a diagnosis of herpes zoster was made and treated with amenamevir. On admission, neurological examination revealed mild cognitive disturbance, mydriasis, weakness of the inferior rectus muscle of the left eye, and right peripheral facial nerve palsy. Cerebrospinal fluid (CSF) analysis showed elevated leukocytes and increased protein levels. Antibody index to varicella-zoster virus (VZV) was elevated in CSF to 25.6, although VZV DNA was negative by PCR. Head CT revealed multiple intracerebral hemorrhages in the left dorsal pons, left ventral midbrain, left thalamus, and left front-parietal lobe. MR angiography detected cerebral artery stenosis. In addition to intravenous acyclovir, the patient was treated with steroid pulse therapy and steroid tapering therapy. One month after admission, his symptoms improved. We diagnosed him with VZV vasculopathy. We believe that multiple intracerebral hemorrhages due to VZV vasculopathy caused facial and oculomotor nerve palsy. Our findings suggest that cerebral hemorrhage induced by VZV vasculopathy must be considered when differentiating cranial nerve palsy after herpes zoster.

Endoscopic management of brainstem injury due to ventriculoperitoneal shunt placement.

INTRODUCTION: We report a patient who suffered from brainstem injury following ventriculoperitoneal (VP) shunt placement in the fourth ventricle. DISCUSSION: A 20-year-old man with complex hydrocephalus and trapped fourth ventricle underwent a suboccipital placement of a VP shunt. Postprocedure patient developed double vision. Magnetic resonance imaging showed that the catheter was penetrating the dorsal brainstem at the level of the pontomedullary junction. Patient was referred to our Neuroendoscopic Clinic. Physical exam demonstrated pure right VI cranial nerve palsy. Patient underwent flexible endoscopic exploration of the ventricular system. Some of the endoscopic findings were severe aqueductal stenosis and brainstem injury from the catheter. Aqueductoplasty, transaqueductal approach into the fourth ventricle, and endoscopic repositioning of the catheter were some of the procedures performed. Patient recovered full neurological function. The combination of endoscopic exploration and shunt is a good alternative for patients with complex hydrocephalus. A transaqueductal approach to the fourth ventricle with flexible scope is an alternative for fourth ventricle pathology.

Neurosarcoidosis presenting with a partial Claude syndrome.

Neurosarcoidosis when encountered by neurologists most commonly presents as cranial neuropathy, peripheral mononeuropathy,polyneuropathy, myopathy, meningitis or myelopathy. There are limited reports in the current literature on the cases of neurosarcoidosis patients presenting with ischaemic stroke. We discuss a 52-year-old patient with a known previous history of cutaneous sarcoidosis presenting with an acute third nerve palsy, facial weakness and ataxia. His magnetic resonance imaging (MRI) brain demonstrated focal signal changes in the midbrain consistent with an acute ischaemic event in the region of his third nucleus, suggesting a partial Claude syndrome presentation. Cerebrospinal fluid (CSF) examination demonstrated an elevated angiotensin-converting enzyme (ACE) level. We discuss the difficulties associated with confirming a diagnosis for his presentation and consider distinctions in stroke in neurosarcoid and its management in comparison to more common causes.

Multiple cranial nerve palsies following radiofrequency ablation for trigeminal neuralgia.

A 33-year-old man developed diffuse subarachnoid haemorrhage following attempted radiofrequency ablation for trigeminal neuralgia. Over the next 2 weeks, he progressively developed multiple bilateral cranial nerve palsies, bilateral cerebellar signs, hypotonia of all four limbs and diminished vision in both eyes. A visual-evoked potential study revealed anterior visual pathway defect. A possibility of demyelination was considered and he was treated with corticosteroids. His neurological deficits improved gradually over the next 4 months. He later underwent microvascular decompression uneventfully with good pain relief. This complication has not been reported earlier and needs to be kept in mind while performing radiofrequency ablation.

Minimally Invasive Alternative Approaches to Pterional Craniotomy: A Systematic Review of the Literature.

OBJECTIVE: Minimally invasive alternatives to the pterional craniotomy include the minipterional and the supraorbital craniotomy (SOC). The latter is performed via either an eyebrow or an eyelid skin incision. The purpose of this systematic review was to analyze the type and the incidence of approach-related complications of these so-called "keyhole craniotomies". METHODS: We review pertinent articles retrieved by search in the PubMed/Medline database. Inclusion criteria were all full-text articles, abstracts, and posters in English, up to 2016, reporting clinical results. RESULTS: A total of 105 articles containing data on 5837 surgeries performed via a minipterional or either of the 2 variants of the SOC met the eligibility criteria. Pain on mastication was the most commonly reported approach-related complication of the minipterional approach, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the SOC eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant. CONCLUSIONS: Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice.

Ramsay Hunt Syndrome with Multiple Cranial Neuropathy in an Human Immunodeficiency Virus (HIV) Patient.

BACKGROUND Ramsay Hunt syndrome is a rare otologic complication resulting from varicella zoster virus reactivation that can present with a myriad of clinical presentations. Most common being triad of ear pain, vesicles at auricle, and ear canal with same side facial palsy. CASE REPORT We report a case of a 29-year-old male with a human immunodeficiency virus (HIV) infection who presented with left facial palsy, vesicles, pain in the left ear, dysphagia, dizziness, and headache resulting from multiple cranial nerves involvement such as cranial nerve V, VII, VIII, IX, and X. CONCLUSIONS This case report raises awareness among general practitioners to investigate for Ramsay Hunt syndrome in HIV patients presenting with ear pain with a thorough neurological exam and emphasize on the interplay of different specialties in managing these patients.

Hypoglossal canal schwannoma causing isolated left 12th cranial nerve palsy.

A 40-year-old woman presented with insidious onset, gradually progressive dysarthria and inability to manoeuvre bolus of food in her mouth while eating. The duration of her symptoms was 3 months. On evaluation, the left half of her tongue was wasted. The tongue deviated to the left on protrusion. There were no clinical features suggestive of involvement of the ipsilateral 9th, 10th or 11th cranial nerves. MRI of the brain showed a large, fusiform lesion in the left hypoglossal canal, extending into the jugular canal. The lesion was surgically excised and found to be a schwannoma.