Acute Transient Oculomotor Nerve Palsy from Presumed Cavernous Angioma in an Infant

Cavernous Angioma Originating Directly from the Oculomotor Nerve: To Treat or Not to Treat?

Cavernous angiomas (CA) affecting cranial nerves (CN) are exceptionally rare. Most reported cases involve the optic nerves, with even fewer occurrences in other CN. In this report, the authors describe a case of an extra-axial CA affecting the oculomotor nerve, which was managed conservatively. The authors also review the outcomes of other therapeutic options based on cases documented in the existing literature. Case report: 36-year-old woman presented to the Emergency Department with a headache in the left temporal region, predominantly at night, along with mild left palpebral ptosis and binocular diplopia of 2 months duration. Brain MRI revealed a lesion exhibiting typical characteristics of CA in the left lateral region of the interpeduncular cistern, in close contact with the left oculomotor nerve. After considering treatment options and in consultation with the patient, a conservative management plan with periodic MRI follow-up was chosen. After 2 years of follow-up, the patient showed favorable progress. Although exceptional, CA should be considered in the differential diagnosis of other more common extra-axial lesions involving CN. The therapeutic management of a CA of the oculomotor nerve remains controversial due to the limited number of cases described in the literature. The authors suggest that for individuals with asymptomatic or mildly symptomatic CA affecting the oculomotor nerve, a conservative treatment approach is the most suitable choice to preserve neurological function. In cases characterized by progressive symptoms, a history of recurrent bleeding, or evidence of lesion enlargement on sequential imaging assessments, total microsurgical resection should be considered.

An isolated cavernous malformation of the sixth cranial nerve: A case report and review of literature

Background

Isolated cavernous malformation (CM) of the abducens nerve has not been reported in the literature. Herein, the authors address the clinical importance of these lesions and review the reported cases of CM from 2014 to 2020.

Case Description

A 21-year-old man presented with binocular diplopia and headache from 2 months before his admission. The neurological examination revealed right-sided abducens nerve palsy. The brain MRI revealed an extra-axial pontomedullary lesion suggestive of a CM. The lesion was surgically removed. During the operation, the abducens nerve was resected considering the lesion could not be separated from the nerve and an anastomosis was performed using an interposition nerve graft and fibrin glue. Pathological examination of the resected lesion revealed that it was originated from within the nerve. The patient's condition improved in postoperative follow-ups.

Conclusion

Surgical resection of the cranial nerves CMs is appropriate when progressive neurological deficits are present. If the lesion is originated from within the nerve, we suggest resection of the involved nerve and performing anastomosis. Novel MRI sequences might help surgeons to be prepared for such cases and fibrin glue can serve as an appropriate tool to perform anastomosis when end-to-end sutures are impossible to perform.

Functional outcome after surgical treatment of cavernous malformation involving ocular motor cranial nerves: A systematic review

Cavernous malformations (CMs) of cranial nerves (CN) III, IV, and VI are extremely rare, and limited studies have assessed functional outcomes after treatment. This systematic review investigated the clinical features of CMs in ocular motor CNs, including the treatment results, and compared different surgical methods for functional preservation of ocular motor CNs. 'PubMed', 'SCOPUS', 'Web of Science', and 'Google Scholar' databases were searched to identify case reports and studies published between January 1980 and December 2018. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-seven patients were identified (median age, 46 years; range, 3 months-71 years). CN III was involved in 17 patients (63.0%), CN IV in 8 (29.6%), and CN VI in 2 (7.4%). Treatments included gross total resection (GTR) and nerve transection in 6 patients (22.2%), GTR and nerve continuity preservation in 7 (25.9%), subtotal resection (STR) and nerve continuity preservation in 4 (14.8%), GTR and end-to-end anastomosis in 5 (18.5%), and conservative care in 3 (11.1%), while the treatment method for 2 (7.4%) patients has not been described in the literature. In 22 patients who underwent surgical treatment, functional changes included improvement in 9 patients (40.9%), no change in 10 (45.5%), and worsening symptoms in 3 (13.6%). Functional preservation was achieved in 12 (54.5%) of the 22 patients; the nerve continuity preservation method conferred a significant advantage for functional preservation compared with other surgical methods (p = 0.004). Functional preservation of ocular motor CNs can be achieved by nerve continuity preservation.