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Inicio Neurología (English Edition) Isolated sixth nerve palsy: an unusual manifestation of preeclampsia
Journal Information
Vol. 34. Issue 9.
Pages 620-621 (November - December 2019)
Vol. 34. Issue 9.
Pages 620-621 (November - December 2019)
Letter to the Editor
DOI: 10.1016/j.nrleng.2017.07.008
Open Access
Isolated sixth nerve palsy: an unusual manifestation of preeclampsia
Neuropatía aislada del sexto nervio craneal. Una manifestación inusual de preeclampsia
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A.E. Baidez Guerreroa, N. García Laxb, R. Hernández Claresc,
Corresponding author
rociohernandezclares@gmail.com

Corresponding author.
, J.J. Martín Fernándeza
a Servicio de Neurología, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
b Sección de Neurología, Hospital Universitario Reina Sofía, Murcia, Spain
c Consulta de Neurooftalmología, Servicio de Neurología, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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Table 1. Blood test at admission.
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Dear Editor:

Preeclampsia is a pregnancy complication of unknown aetiology with an estimated frequency of 2%–8%. It is characterised by hypertension after week 20 of gestation in women with previously normal blood pressure, together with proteinuria, or in the absence of proteinuria but with presence of thrombocytopaenia, kidney failure, altered liver function, pulmonary oedema, or neurological symptoms.1 The most frequent neurological symptoms include headache and visual alterations, with isolated oculomotor palsy being exceptional.2 We present the case of a primiparous woman (37 weeks pregnant) whose first neurological symptom of preeclampsia was sixth nerve palsy; we also assess the possible action mechanisms.

Our patient was a 31-year-old woman assessed in the emergency department due to progressive onset of binocular diplopia in the horizontal plane, with no headache, fever, or other focal neurological signs. The neuro-ophthalmological evaluation revealed 20/20 Snellen visual acuity in both eyes, and the eye fundus examination showed well-defined papillae and spontaneous venous pulsation; the confrontation visual field test yielded normal results; esotropia was observed in the primary gaze position with slightly impaired adduction of the left eye. No other neurological alterations were observed. The general examination detected no fever, blood pressure values of 150/90mm Hg, and distal oedema in both lower limbs; a blood analysis revealed thrombocytopaenia with 100000platelets/μL, increased LDH levels (418IU/L), and proteinuria (Table 1). In view of these symptoms, and considering the diagnosis of preeclampsia and findings suggestive of isolated sixth nerve palsy, we requested an MRI study before labour was induced. The MRI study ruled out an underlying intracranial lesion, and labour was induced 24hours after the patient's admission to hospital; a healthy baby was born with no complications. After delivery, the patient presented normal blood pressure values and diplopia progressively improved, fully resolving in 48hours.

Table 1.

Blood test at admission.

Peripheral blood    Biochemical study        Urine analysis 
Haemoglobin  11.6g/dL  Total protein  5g/dL  Lactate dehydrogenase  418IU/L  Protein++ 
Haematocrit  56.2%  Albumin  2.7g/dL  GOT  9IU/L   
MCV  85.0fL  Urea  12mg/dL  GPT  13IU/L   
        Glucose  95mg/dL   
Platelets  10×104/μL  Creatinine  0.9mg/dL       
ESR  20mm/h  Uric acid  6.7mg/dL       
Leukocytes  14380/μL  Alkaline phosphatase  110IU/L       

ESR: erythrocyte sedimentation rate; GOT: glutamic oxaloacetic transaminase; GPT: glutamate-pyruvate transaminase; MCV: mean corpuscular volume.

Isolated sixth nerve or abducens nerve palsy during pregnancy is exceptional, although isolated cases have been reported.3–6 The action mechanism by which preeclampsia causes neuropathy remains unknown, although the absence of other findings and previous published data in the literature suggest that it may cause vasospasm of the vasa nervorum, causing transient ischaemia that would lead to nerve palsy.6 In our patient, who had no history suggesting an underlying systemic disease, presenting preeclampsia and no fever, intracranial hypertension, or underlying intracranial lesion on MR images, together with the complete resolution of symptoms postpartum, suggest preeclampsia-related sixth nerve palsy.

References
[1]
G. Lambert, J.F. Brichant, G. Hartstein, V. Bonhomme, P.Y. Dewandre.
Preeclampsia: an update.
Acta Anaesthesiol Belg, 65 (2014), pp. 137-149
[2]
S. Thamban, V. Nama, R. Sharma, P.J. Kollipara.
Abducens nerve palsy complicating pregnancy.
J Obstet Gynaecol, 26 (2006), pp. 811-812
[3]
C. Barry-Kinsella, M. Milner, N. McCarthy, J. Walshe.
Sixth nerve palsy: an unusual manifestation of preeclampsia.
Obstet Gynecol, 83 (1994), pp. 849-851
[4]
M.J. Thurtell, K.L. Sharp, J.M. Spies, G.M. Halmagyi.
Isolated sixth cranial nerve palsy in preeclampsia.
J Neuro-Ophthalmol, 26 (2006), pp. 296-298
[5]
C.M. Park, S.Y. Kim.
Abducens nerve palsy in preeclampsia after delivery: an unusual case report.
J Obstet Gynaecol Res, 33 (2007), pp. 543-545
[6]
A.J. Vallejo-Vaz, P. Stiefel, V. Alfaro, M.L. Miranda.
Isolated abducens nerve palsy in preeclampsia and hypertension in pregnancy.
Hypertens Res, 36 (2013), pp. 834-835

Please cite this article as: Baidez Guerrero AE, García Lax N, Hernández Clares R, Martín Fernández JJ. Neuropatía aislada del sexto nervio craneal. Una manifestación inusual de preeclampsia. Neurología. 2019;34:620–621.

Copyright © 2017. Sociedad Española de Neurología
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