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Bilateral sixth cranial nerve palsy after unintentional dural puncture

[Paralysie bilatérale du sixième nerf crânien à la suite d’une brèche durale accidentelle]

Geneviève Arcand, MD^*, François Girard, MD FRCPC^*, Michael McCormack, MD FRCSC, Philippe Chouinard, MD FRCPC^*, Daniel Boudreault, MD FRCPC^* and Stephan Williams, MD PHD^*

^* From the Departments of Anesthesiology, and
Surgery, CHUM, Notre-Dame Hospital, Montréal, Québec, Canada.

Address correspondence to: Dr. François Girard, Department of Anesthesiology, CHUM, Hôpital Notre-Dame, 1560 Sherbrooke East, Montréal, Québec H2L 4M1, Canada. Phone: 514-890-8000, ext. 26876; Fax: 514-412-7653; E-mail: francois.girard.chum{at}ssss.gouv.qc.ca

Purpose: Bilateral sixth nerve palsy is a known though uncommon complication following dural puncture. The recommended treatment consists of hydration and alternate monocular occlusion. The value and the timing of an epidural blood patch (EBP) for sixth nerve palsy remains controversial as some authors have demonstrated benefits in performing an EBP early in course of the nerve palsy whereas others have not found any advantage when an EBP was performed later.

Clinical features: A 40-yr-old woman developed bilateral sixth nerve palsy ten days after an unintentional dural puncture. An EBP was done within 24 hr after the onset of the symptoms and immediate improvement of the diplopia was noted by the patient and confirmed by an ophthalmologist. Complete resolution of the diplopia occurred 36 days after the dural puncture.

Conclusion: Blood patching within 24 hr of the onset of diplopia may be a reasonable treatment for ocular nerve palsy as it relieved the postdural puncture headache and produced partial improvement of the diplopia.

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