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Isolated bilateral abducens nerve palsy secondary to clivus metastasis of prostate adenocarcinoma undetected by magnetic resonance imaging
Paresia del nervio abducens bilateral aislada secundaria a metástasis en clivus de adenocarcinoma de próstata inadvertida en resonancia magnética
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Secuencia T1 con contraste: A) corte axial, B) corte sagital. Flecha roja: nervio abducens izquierdo, emergiendo desde la cisterna prepontina, hipercaptante probablemente por afectación en el conducto de Dorello. Flecha verde: nervio trigémino, sin captación de contraste. C y D) TC craneal con ventana hueso. Corte axial: C) se observa aumento difuso de la densidad ósea a nivel del clivus y esfenoides (asterisco rojo) sugestivo de infiltración ósea metastásica, D) imagen de paciente control, sin aumento de la densidad ósea en base de cráneo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Mayà-Casalprim, E. Serrano, H.K. Oberoi, L. Llull" "autores" => array:4 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Mayà-Casalprim" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Serrano" ] 2 => array:2 [ "nombre" => "H.K." "apellidos" => "Oberoi" ] 3 => array:2 [ "nombre" => "L." 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C) Limitations in thumb abduction. D) Long toes in both feet.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D.M. Fernández-Mayoralas, B. Calleja-Pérez, S. Álvarez, A. Fernández-Jaén" "autores" => array:4 [ 0 => array:2 [ "nombre" => "D.M." "apellidos" => "Fernández-Mayoralas" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Calleja-Pérez" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Álvarez" ] 3 => array:2 [ "nombre" => "A." 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Roche Bueno" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J.C." 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Mayà-Casalprim, E. Serrano, H.K Oberoi, L. Llull" "autores" => array:4 [ 0 => array:3 [ "nombre" => "G." "apellidos" => "Mayà-Casalprim" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Serrano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "H.K" "apellidos" => "Oberoi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "L." "apellidos" => "Llull" "email" => array:1 [ 0 => "BLLLULL@clinic.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Sagrat Cor, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oncología, Hospital Clínic, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paresia del nervio abducens bilateral aislada secundaria a metástasis en clivus de adenocarcinoma de próstata inadvertida en resonancia magnética" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 462 "Ancho" => 1300 "Tamanyo" => 68607 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Upward gaze with no alterations. B) Rightward gaze, with partial abduction of the right eye. C) Primary position, with bilateral esotropia. D) Leftward gaze, with mildly impaired abduction of the left eye. E) Downward gaze, with mild right eye esotropia. Preserved convergence (not shown). Examination performed after 14 days of treatment, with partial improvement, mainly of the left abducens nerve (increased contrast uptake on MRI). Diplopia persisted.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bilateral abducens nerve palsy has numerous causes, including cerebrovascular diseases, intracranial hypertension, carotid-cavernous fistulas, infection, trauma, Guillain–Barré syndrome, Wernicke–Korsakoff syndrome, and tumours. The condition rarely presents in isolation; when it does, presence of a tumour in the clivus should be ruled out. We present a case of bilateral abducens nerve palsy secondary to clival metastasis of prostate cancer.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 72-year-old man with 6-year history of prostate adenocarcinoma and bone metastases who visited our emergency department in March 2018 due to diplopia of 2 months’ progression; he was receiving sixth-line treatment with radium-223 and had already completed 4 cycles, showing good tolerance. He initially reported difficulty with left eye abduction, developing difficulty with right eye abduction 2 weeks later.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The most recent imaging studies available, performed a month previously, were bone scintigraphy, which revealed bone lesions in multiple sites, including the skull and the left superior maxillary bone (see online supplementary material), and a chest and abdominal axial CT scan, which revealed no visceral anomalies. A week previously, the patient had undergone a brain MRI study, which was initially interpreted as normal; however, a later evaluation of MR images detected contrast uptake in the left abducens nerve (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An electromyography study conducted the previous day had yielded normal results.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The neurological examination detected isolated bilateral abducens nerve palsy (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A blood analysis detected no abnormalities; acute-phase reactants were within normal ranges. A head CT bone window study revealed diffuse hyperdensities in the clivus and sphenoid bones, suggestive of bone metastases (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We started outpatient treatment with dexamethasone dosed at 4 mg/24 h, which was later down-titrated, and skull base radiation therapy (total dose of 30 Gy); given the progression of the cancer, treatment was switched to a new line of chemotherapy with cabazitaxel. Diplopia resolved within 4 weeks, and has not reappeared after 6 months of follow-up. No follow-up neuroimages are available.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The abducens nerve innervates the lateral rectus muscle, responsible for eye abduction. Its trajectory is subdivided into 5 segments<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0035" class="elsevierStylePara elsevierViewall">Intra-axial: the abducens nucleus is located in the posterior, caudal portion of the pons. It projects axons anteriorly through the medial lemniscus, which is medial to the fascicles of the facial nerve.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0040" class="elsevierStylePara elsevierViewall">Cisternal: the abducens nerve emerges at the pontomedullary sulcus, lateral to the bundles of the corticospinal tract, and courses upwards along the prepontine cistern until reaching the posterior, dural surface of the clivus.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0045" class="elsevierStylePara elsevierViewall">Dorello canal: after perforating the clival dura mater, the abducens nerve enters the Dorello canal to reach the cavernous sinus.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cavernous sinus: the abducens nerve runs immediately lateral to the internal carotid artery.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0055" class="elsevierStylePara elsevierViewall">Extracranial: the abducens nerve enters the orbit through the superior orbital fissure and reaches the lateral rectus muscle.</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">A clival lesion may therefore damage the abducens nerve bilaterally at the level of the Dorello canal.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The literature includes only 12 cases of isolated bilateral abducens nerve palsy secondary to tumours of varying aetiology. In 7 patients (3 with primary tumours and 4 with metastases), the clivus was the main structure involved: clivus chordoma (2),<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> multiple myeloma of the clivus (1),<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> clivus diffuse large B cell lymphoma (1),<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> clivus metastasis of Ewing’s sarcoma (1),<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> clivus metastasis of small-cell lung carcinoma (1),<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and clivus metastasis of lung adenocarcinoma (1).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The remaining 5 patients had pituitary adenoma (3),<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10-12</span></a> primary non-Hodgkin’s lymphoma of the sphenoid sinus (1),<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and nasopharyngeal carcinoma (1).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The primary tumour was previously unknown in only one of the 3 patients presenting metastasis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In some patients, abducens nerve palsy was bilateral from diagnosis, whereas other patients initially presented unilateral symptoms, with bilateral palsy developing over the course of several days or weeks.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Our case shows that bone metastases may go undetected in contrast brain MRI scans; head CT scans, particularly bone window images, may be extremely helpful for diagnosis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first reported case of isolated bilateral abducens nerve palsy secondary to clival metastasis of prostate adenocarcinoma. Clivus tumours should be included in the differential diagnosis of bilateral abducens nerve palsy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have received no funding for this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-12-13" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mayà-Casalprim G, Serrano E, Oberoi HK, Llull L. Paresia del nervio abducens bilateral aislada secundaria a metástasis en clivus de adenocarcinoma de próstata inadvertida en resonancia magnética. Neurología. 2020;35:599–601.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0095" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0020" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1372 "Ancho" => 1255 "Tamanyo" => 150567 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A and B) Brain MRI. Contrast T1-weighted sequences: A) axial plane; B) sagittal plane. Red arrow: the left abducens nerve, emerging from the prepontine cistern, shows increased contrast uptake, probably due to involvement of the Dorello canal. Green arrow: trigeminal nerve, with no contrast uptake. C and D) Head CT scan (bone window), axial plane. C) Diffuse hyperdensities in the clivus and sphenoid bone (red asterisk), suggesting bone metastases. D) Image from a control, showing no hyperdensities at the base of the skull.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 462 "Ancho" => 1300 "Tamanyo" => 68607 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Upward gaze with no alterations. B) Rightward gaze, with partial abduction of the right eye. C) Primary position, with bilateral esotropia. D) Leftward gaze, with mildly impaired abduction of the left eye. E) Downward gaze, with mild right eye esotropia. Preserved convergence (not shown). Examination performed after 14 days of treatment, with partial improvement, mainly of the left abducens nerve (increased contrast uptake on MRI). Diplopia persisted.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.zip" "ficheroTamanyo" => 319462 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "[1]" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Examen neurológico. 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