MRI in isolated sixth nerve palsies

In previous studies the origin of the majority of isolated sixth nerve palsies was not clear or was ascribed to vascular disease. Our purpose was determine how frequently a causative lesion was demonstrated on MRI in patients with an acute unilateral sixth nerve palsy. We performed a prospective study of 43 patients using a standardised protocol. In 27 patients (63 %) a lesion was identified on the initial MRI relevant to the sixth nerve palsy; 21 (49 %) were found to have a tumour or tumour-like lesion; the frequency of presumed vasculopathy in this group was 15 %. There were 16 patients (37 %) with an initially normal MRI, of whom 10 (62 %) had a history of vasculopathy, a significantly different proportion from the group of patients with a visible causative lesion. MRI after 3-6 months was normal in all patients with a normal initial MRI. We suggest that MRI should routinely be performed in patients presenting with an acute sixth nerve palsy, even those with evidence of a vasculopathy. If the symptoms regress spontaneously and there is a history of vasculopathy, follow-up MRI is not necessary.