Sixth Cranial Nerve Paresis Secondary to Intracranial Hypotension: Etiology, Clinical Characteristics, and Treatment

Intracranial hypotension is a typically self-limiting or treatable condition characterized by orthostatic headache and neck stiffness. However, it may be severe and may be associated with neurological complications, particularly sixth cranial nerve palsy. We report two young women who presented to the emergency department with diplopia secondary to acute unilateral sixth cranial nerve paresis in the context of intracranial hypotension following anesthetic procedures. In both cases, clinical and radiological findings consistent with a cerebrospinal fluid (CSF) deficit were documented, including bilateral subdural collections in one case. One case required an epidural blood patch, which resulted in complete resolution, whereas the other resolved spontaneously. The clinical manifestations, radiological findings, and therapeutic options are reviewed. These cases underscore the importance of careful clinical and radiological assessment in patients with acute ophthalmoplegia, in whom orthostatic headache is a key diagnostic clue, as well as of treatment aimed at correcting the CSF deficit.