Third nerve palsy: Difference between revisions
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== Background | ==Background== | ||
[[File:Gray785.png|thumb|Figure showing the mode of innervation of the recti lateralis from CNII.]] | |||
*Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique) | [[File:Capture2.PNG|thumbnail|Right eye]] | ||
[[File:Extraocular muscle actions and innervation.png|thumb|Eye movements by extra-ocular muscles and cranial nerve innervation]] | |||
*Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique) <ref>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.</ref> | |||
*Nerve also carries parasympathetic fibers on external surface allowing for pupillary constriction | *Nerve also carries parasympathetic fibers on external surface allowing for pupillary constriction | ||
*Palsy causes [[Diplopia|diplopia]] except in lateral gaze (lateral rectus innervated by CN VI) | *Palsy causes [[Diplopia|diplopia]] except in lateral gaze (lateral rectus innervated by CN VI) | ||
*Ptosis, headache | *Ptosis, [[headache]] | ||
== Causes | ===Causes=== | ||
*[[Posterior Communicating Artery (PCOM) Aneurysm]] (compresses nerve) | |||
*Posterior Communicating Artery Aneurysm | |||
*Ischemia | *Ischemia | ||
**Diabetes | **[[Diabetes]] | ||
*Trauma | *[[Trauma]] | ||
**Temporal lobe herniation through tentorium | **Temporal lobe [[herniation Syndromes|herniation]] through tentorium | ||
*[[Myasthenia Gravis]] | *[[Myasthenia Gravis]]<ref>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. </ref> | ||
*[[Cavernous Sinus Thrombosis]] | *[[Cavernous Sinus Thrombosis]] | ||
**often associated with other cranial nerve | **often associated with other [[cranial nerve palsies|cranial nerve deficits]] | ||
* | *[[Neurosyphilis]] | ||
*Autoimmune vasculitis ([[Systemic Lupus Erythematosus|Lupus]]) | *Autoimmune [[vasculitis]] ([[Systemic Lupus Erythematosus|Lupus]]) | ||
*Aneurysm <ref>Chaudhary,N. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. J. Neuro-Ophthalmol 2009;29:238-244</ref> | |||
*[[Carotid-cavernous fistula]] | |||
*[[intracranial mass|Mass ]] | |||
*[[Myasthenia gravis]] | |||
*[[Thyroid]] associated orbitopathy | |||
*[[Internuclear ophthalmoplegia]] | |||
*[[Giant cell arteritis]] | |||
==Clinical Features== | |||
[[File:PMC4134542 OJO-7-103-g001.png|thumb|Complete (isolated) third nerve palsy showing (a) left-sided ptosis, (b) restricted adduction movement of left eyeball, and (c) normal abduction movement of left eyeball.]] | |||
*Eye deviates laterally and down | *Eye deviates laterally and down | ||
*Pupil exam: | *Pupil exam: | ||
Line 28: | Line 35: | ||
*Loss of accommodation | *Loss of accommodation | ||
== | ==Differential Diagnosis== | ||
===Monocular Diplopia=== | |||
*Cataract | |||
*[[Lens dislocation]] | |||
*Macular disruption | |||
== | |||
===Binocular Diplopia=== | |||
: | *Basilar Artery Thrombosis | ||
*[[Posterior Communicating Artery (PCOM) Aneurysm|Posterior communicating artery (PCOM) aneurysm]] | |||
*[[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> | |||
*[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]] | |||
*[[Botulism]] | |||
*[[Cavernous sinus thrombosis]] | |||
*[[Intracranial mass]], brainstem mass | |||
*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]] | |||
*[[Hyperthyroidism | Hyperthyroid]] Proptosis | |||
*Basilar [[Meningitis]] | |||
*[[Stroke (Main) |CVA]] | |||
*Muscular Entrapment from [[Maxillofacial Trauma |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 | *If ischemic cause | ||
**Medical management with most self resolving in 6-8 | **Medical management, plus or minus [[ASA]], with most self resolving in 6-8 weeks | ||
**Ophthalmology | **Ophthalmology follow up | ||
*If aneurysm/mass | *If aneurysm/mass | ||
**Neurosurgery consult | **Neurosurgery consult | ||
*If diplopia | *If [[diplopia]] | ||
**No driving or operating heavy machinery | |||
== | ==See Also== | ||
* | *[[Cranial nerves]] | ||
* | *[[Diplopia]] | ||
* | *[[Ocular palsy]] | ||
==References== | |||
<references/> | |||
[[Category: | [[Category:Ophthalmology]] | ||
[[Category:Neurology]] | |||
[[category:Symptoms]] |
Latest revision as of 16:21, 26 September 2020
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