Delayed onset sequential bilateral abducens nerve palsies secondary to traumatic CSF leak

Area of Science:

• Neurology
• Neurosurgery
• Ophthalmology

Background:

• Abducens nerve palsy is a known complication of head trauma due to the nerve's long and vulnerable anatomical course.
• Bilateral abducens palsies secondary to non-iatrogenic intracranial hypotension are rare.

Observation:

• A case report of a male patient experiencing sequential delayed onset abducens nerve palsies after head and neck trauma.
• Intracranial hypotension was diagnosed, secondary to a cerebrospinal fluid (CSF) leak from a dural tear at the C6/7 level, confirmed by magnetic resonance imaging (MRI).
• The patient's clinical course was complicated by pulmonary embolism and prolonged immobility.

Findings:

• A hypothesis suggests that the continuous traction from the CSF leak caused the sequential abducens nerve palsies.
• Conservative management, including bed rest, fluids, and caffeine, led to a good response with resolving abducens dysfunction within ten weeks.
• Surgical interventions like epidural blood patch or fixation were deemed unnecessary and unlikely to succeed due to the dural tear's location and the patient's anticoagulation status.

Implications:

• Recognizing CSF leak and intracranial hypotension is crucial for diagnosing rare causes of sequential abducens nerve palsy in patients with head and spinal injuries.
• Management strategies for this condition vary from conservative measures to surgical interventions.
• This case underscores the importance of considering non-traumatic causes for abducens nerve palsy, especially in the context of CSF leaks.