Abstract 317: Isolated Sixth Cranial Nerve Palsy as a Rare Manifestation of Iatrogenic Intracranial Hypotension: A Case Report

Introduction/Purpose Iatrogenic intracranial hypotension (IH) is an uncommon complication that arises due to cerebrospinal fluid (CSF) leakage, often following spinal procedures or surgeries. The most common presentation is orthostatic headache. In this case, we describe a rare presentation of IH with sixth cranial nerve palsy. Materials and Methods: A 32‐year‐old female with a past medical history of heterozygous MTHFR gene mutation and seven first‐term spontaneous abortions presented with one‐day history of double vision. One week before the presentation, she had undergone a caesarean section with epidural anesthesia. On the second day after the procedure, she started to experience holocranial headache with a positional component, improving with lying down and worsening upon standing. Five days later, she started to experience double vision. The diplopia was worst on left gaze. It was horizontal, constant, and worse with distance. Physical examination revealed left sixth cranial nerve palsy with esotropia, while the rest of the examination was unremarkable. Ophthalmologic evaluation showed sharp optic discs without vessel obscuration. Laboratory workup was insignificant. Imaging studies included a CT head showing slight prominence of the pituitary gland, a normal CT venogram, and an MRI brain that revealed diffuse dural thickening and enhancement, narrowing of the mamillopontine distance, and distention of the dural venous sinuses—findings consistent with intracranial hypotension. The patient was treated with an epidural blood patch on the day of presentation. Following the blood patch, the patient experienced significant improvement in her headache the next day, though she continued to experience double vision. She was discharged with follow‐up with neurology clinic. Results N/A Conclusion This case highlights the possibility of isolated sixth cranial nerve palsy as a manifestation of intracranial hypotension, likely due to nerve traction secondary to low CSF pressure. It highlights the importance of considering intracranial hypotension as a differential diagnosis in patients presenting with headache and sixth cranial nerve palsy, as it challenges the common association with intracranial hypertension and changes the management.