Third nerve palsy: Difference between revisions
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===Binocular Diplopia=== | ===Binocular Diplopia=== | ||
*Basilar Artery Thrombosis | *Basilar Artery Thrombosis | ||
*[[Posterior Communicating Artery (PCOM) Aneurysm]] | *[[Posterior Communicating Artery (PCOM) Aneurysm|Posterior communicating artery (PCOM) aneurysm]] | ||
*Vertebral artery dissection | *[[vertebral and carotid artery dissection|Vertebral artery dissection]] | ||
*[[Myasthenia Gravis]]<ref>Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239</ref> | *[[Myasthenia Gravis]]<ref>Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239</ref> | ||
*[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]] | *[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]] | ||
*[[Botulism]] | *[[Botulism]] | ||
*[[Cavernous sinus thrombosis]] | *[[Cavernous sinus thrombosis]] | ||
*[[Intracranial | *[[Intracranial mass]], brainstem mass | ||
*Miller Fischer variant [[Guillain- | *Miller Fischer variant [[Guillain-Barre]]<ref>Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430</ref> | ||
*[[Multiple Sclerosis (MS)| MS]] | *[[Multiple Sclerosis (MS)| MS]] | ||
*[[Hyperthyroidism | Hyperthyroid]] Proptosis | *[[Hyperthyroidism | Hyperthyroid]] Proptosis | ||
Revision as of 18:32, 28 September 2019
Background
- Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique) [1]
- Nerve also carries parasympathetic fibers on external surface allowing for pupillary constriction
- Palsy causes diplopia except in lateral gaze (lateral rectus innervated by CN VI)
- Ptosis, headache
Causes
- Posterior Communicating Artery (PCOM) Aneurysm (compresses nerve)
- Ischemia
- Trauma
- Temporal lobe herniation through tentorium
- Myasthenia Gravis[2]
- Cavernous Sinus Thrombosis
- often associated with other cranial nerve deficits
- Neurosyphilis
- Autoimmune vasculitis (Lupus)
- Aneurysm [3]
- Carotid-cavernous fistula
- Mass
- Myasthenia gravis
- Thyroid associated orbitopathy
- Internuclear ophthalmoplegia
- Giant cell arteritis
Clinical Features
- Eye deviates laterally and down
- Pupil exam:
- If dilated/nonreactive likely secondary to space occupying lesion
- If pupil is spared likely ischemic etiology
- Loss of accommodation
Differential Diagnosis
Monocular Diplopia
- Cataract
- Lens dislocation
- Macular disruption
Binocular Diplopia
- Basilar Artery Thrombosis
- Posterior communicating artery (PCOM) aneurysm
- Vertebral artery dissection
- Myasthenia Gravis[4]
- Lambert-Eaton Syndrome
- Botulism
- Cavernous sinus thrombosis
- Intracranial mass, brainstem mass
- Miller Fischer variant Guillain-Barre[5]
- MS
- Hyperthyroid Proptosis
- Basilar Meningitis
- CVA
- Muscular Entrapment from Trauma
- Third nerve palsy
Evaluation
- If complete CNIII involvement with ptosis, mydriasis, and ophtalmoplegia:
- Assume a compressive etiology from an intracranial aneurysm (PCOM aneurysm for example)
- Proceed to a CTA brain
- If complete oculomotor nerve palsy without pupil involvement then strongly favor an ischemic process
- Consider a CTA brain
- Coronal reconstruction on CT will allow visualization of orbits to rule out compressive process
- If associated with other neurologic deficits:
- CTA brain followed by MRI/MRA brain
Management
- If ischemic cause
- Medical management, plus or minus ASA, with most self resolving in 6-8 weeks
- Ophthalmology follow up
- If aneurysm/mass
- Neurosurgery consult
- If diplopia
- No driving or operating heavy machinery
See Also
References
- ↑ Capo, H., M.D., Warren, F., M.D., Kupersmith, M. , M.D. Evolution of Oculomotor Nerve Palsies. J Clin Neuroophthalmol. 1992 Mar;12(1):21-5. (12)1:21-25, 1992.
- ↑ Appenzeller S, Veilleux, M. Clarke, A. Lupus. Third cranial nerve palsy or pseudo 3rd nerve palsy of myasthenia gravis? A challenging diagnosis in systemic lupus erythematosus. 2009 Lupus. Aug;18(9):836-40.
- ↑ Chaudhary,N. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. J. Neuro-Ophthalmol 2009;29:238-244
- ↑ Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239
- ↑ Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430