Possible Post-traumatic Abducens Nerve Palsy in a 16th Century Fresco ('the Chamber of the Giants' by Giulio Romano)

Historical Note Possible Post-traumatic Abducens Nerve Palsy in a 16th Century Fresco (“the Chamber of the Giants” by Giulio Romano) Antonio Perciaccante, MD, Andrei I. Cucu, MD I conodiagnosis is the process of analyzing an artwork by a medical look to find possible represented diseases or pathological signs (1–3). Indeed, art may have an important role in medical training, both in reinforcing practical skills and as examination of cultural and ethical issues (4,5). Here, we report an example of iconodiagnosis that we observed in a particular fresco of the Chamber of the Giants in Palazzo Te, Mantua, Italy. The room was depicted by the Italian painter and architect Giulio Pippi, better known as Giulio Romano (c.1499–1546), one of the pupil of Raphael Santi. He was courted by Federico Gonzaga, the ruler of Mantua, to execute his masterpiece of architecture and fresco painting in Palazzo Te. The most famous chamber of this palace is named the “Chamber of the Giants” (1532–1535), whose frescoes are famous for the lack of spatial constraints other than those generated by the pictorial illusion because of the dynamism and the expressiveness of the images (6). The frescoes tell the story of the Fall of the Giants, taken from The Metamorphoses by the Latin poet Ovid. The scene is set when the Giants attempt to assault the Mount Olympus, but Jupiter throws thunderbolts against them. In a dramatic scene, some of the Giants are hit by the fall of the mountain, others by fastflowing streams of water, and others are knocked down by the collapse of a building. In the fresco on the South wall, we can note the head of a giant trapped among the rocks (Fig. 1). With a more careful observation, we can clearly note a convergent strabismus (esotropia) of the Giant’s left eye (Fig. 2). We do not know whether Giulio Romano deliberately depicted this strabismus maybe to emphasize the drama FIG. 1. Fresco of South wall of the Chamber of the Giants. of the Giant’s expression and of the scene in general, but strabismus do not seem to be present in other Giants’ figures. We can hypothesize a unilateral palsy of the sixth nerve (abducens nerve) and can propose a traumatic etiology. The sixth nerve is responsible for ipsilateral abduction, and in the event of its injury, esotropia occurs due to paresis of the lateral rectus muscle. Traumatic unilateral paralysis of the abducens nerve occurs in Department of Medicine (AP), Azienda Sanitaria Universitaria Giuliano Isontina, “San Giovanni di Dio” Hospital, Gorizia, Italy; Laboratoire Anthropologie Archéologie Biologie (LAAB) (AP), Université Paris-Saclay, UFR des Sciences de La Santé, Montigny-le-Bretonneux, France; and Department of Neurosurgery (AIC), N. Oblu Clinical Emergency Hospital, Iasi, Romania. The authors report no conflicts of interest. Address correspondence to Antonio Perciaccante, MD, Department of Medicine, Azienda Sanitaria Universitaria Giuliano Isontina, “San Giovanni di Dio” Hospital, Via Fatebenefratelli, 34, 34170 Gorizia, Italy; E-mail: [e-mail] Perciaccante and Cucu: J Neuro-Ophthalmol 2021; 41: e401-e402 FIG. 2. Giant’s eyes (particular). e401 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Historical Note TABLE 1. Location and signs of cranial nerve 6 lesion Anatomical Course of Abducens Nerve Brainstem (pons) Cerebellopontine angle Subarachnoid course Petrous bone Cavernous sinus and superior orbital fissure Orbit Possible Associated Signs/Symptoms Other cranial nerve palsies (V, VII, and VIII) Other cranial nerve palsies (VII and VIII) Signs of raised intracranial pressure Other cranial nerve palsies (V, VII, and VIII) Other cranial nerve palsies (III, IV, and VI) and Horner syndrome Chemosis, proptosis, swelling, and lacerations 1%–2.7% of head injuries (7). Post-traumatic bilateral abducens palsy is quite rare. Isolated abducens nerve palsy results from injury of the nerve, along its course, from the brainstem to the lateral rectus muscle (Table 1). The abducens nerve leaves the brainstem at the pontomedullary junction and ascends vertically through the subarachnoid space, penetrates the dura mater after approximately 15 mm of trajectory, goes vertically along the ridge of the petrous bone, and then crosses over the petrous apex, where it changes direction by 120°. From this point, the nerve crosses under the petroclinoid ligament (the Gruber ligament), then through the cavernous sinus, lateral to the internal carotid artery, and enters in the orbit through the superior orbital fissure, where it finally innervates the lateral rectus muscle (8). Owing to its considerable intracranial length and multiple angulations along its course, the sixth nerve is vulnerable to injury. Although this nerve is shorter than the trochlear nerve, it is more vulnerable because it has 3 angulation points between the dural entrance points (9). The most vulnerable area is acute angulation at the petroclival dural entrance point (entrance to the Dorello canal) because of the tethering of the nerve in the Dorello canal (9). Postmortem studies have suggested that dural entry and exit, as well as the petrous apex, are the most common sites of damage to this nerve, and nerve injury is directly proportional to the severity of the head injury (10). Abducens nerve injury occurs as a result of significant kinetic forces (8), and it has been proposed that the nerve will be contused as the brain accelerates and decelerates. e402 While the petroclival portion of the nerve remains fixed, intraneural edema and perineural hemorrhage will seem secondary, especially within the petroclival segment (11). The stones around the Giant’s head suggest that the calvarium was the primary site of impact, with the secondary occurrence of craniocervical junction’s distraction injury. In conclusion, we report a possible case of esotropia due to abducens nerve palsy consequent to a head trauma in a fresco of the 16th century. Consideration of this underlines a complementary role of more art in medical training. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: A. Perciaccante; b. Acquisition of data: A. Perciaccante and A. I. Cucu; c. Analysis and interpretation of data: A. Perciaccante and A. I. Cucu. Category 2: a. Drafting the manuscript: A. Perciaccante and A. I. Cucu; b. Revising it for intellectual content: A. Perciaccante and A. I. Cucu. Category 3: a. Final approval of the completed manuscript: A. Perciaccante and A. I. Cucu. REFERENCES 1. Heneghan C, Glasziou P, Thompson M, Rose P, Balla J, Lasserson D, Scott C, Perera R. Diagnostic strategies used in primary care. BMJ. 2009;338:b946. 2. Perry M, Maffulli N, Willson S, Morrissey D. The effective- ness of arts-based interventions in medical education: a literature review. 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