Reversible abducens nerve palsy following cranial vault expansion in the setting of multisutural craniosynostosis: illustrative case

Abstract

Background: Posterior cranial vault distraction osteogenesis (PVDO) is a commonly used cranial expansion procedure in infants and children with syndromic craniosynostosis. To date, there have been no reports of cranial nerve (CN) palsies in patients undergoing univector PVDO.

Observations: In this article, the authors describe the case of a 27-month-old female with Muenke syndrome who underwent long-distance (> 30 mm) PVDO and developed bilateral abducens nerve (CN VI) palsy after 40 mm of distraction. Following partial reversal of the distraction during the activation phase, the authors observed complete resolution of this palsy.

Lessons: This report demonstrates that CN palsies are a potential complication for which the patient should be monitored, even when undergoing univector PVDO. Most notably, this report illustrates that a gradual reduction in the distraction distance can result in complete resolution of a CN VI palsy while also maintaining a significant degree of intracranial expansion. https://thejns.org/doi/10.3171/CASE24762.

Keywords: CN VI; abducens palsy; cranial nerve VI; craniosynostosis; lateral rectus palsy; posterior cranial vault distraction osteogenesis.

FIG. 1.

Preoperative 3D CT scan. A: Vertex view demonstrating brachycephaly, bifrontal retrusion, and bilateral coronal suture fusion. B: Lateral view.

FIG. 2.

Photograph demonstrating right-sided lateral rectus palsy (red arrow). The child was affected on both sides.

FIG. 3.

Comparison of sagittal (A) and axial (B) intracranial CT scans before distraction and on POD 27.

FIG. 4.

Postoperative 3D CT scans obtained after CN VI palsy was noted. A: Vertex view. B: Lateral view. PVDO was accomplished using two 50-mm devices placed in a low lateral position.