Third nerve palsy: Difference between revisions
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== Work-up == | == Work-up == | ||
#If complete CNIII involvement with ptosis, mydriasis, and ophtalmoplegia: | |||
:assume a compressive etiology from an intracraneal anurysm. | |||
: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 | |||
== Dispo == | == Dispo == |
Revision as of 04:42, 15 January 2014
Background
- Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique)
- 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 Aneurysm
- Compresses nerve
- Ischemia
- Diabetes
- Trauma
- Temporal lobe herniation through tentorium
- Myasthenia Gravis
- Cavernous Sinus Thrombosis
- often associated with other cranial nerve defecits
- Neurosyphillis
- Autoimmune vasculitis (Lupus)
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
DDx
- Aneurysm
- Carotid Cavernous Fistula
- Mass
- Ischemia
- Myasthenia Gravis
- Thyroid associated orbitopathy
- Internuclear opthalmoplegia
- Giant Cell Arteritis
Work-up
- If complete CNIII involvement with ptosis, mydriasis, and ophtalmoplegia:
- assume a compressive etiology from an intracraneal anurysm.
- 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
Dispo
- If ischemic cause
- Medical management with most self resolving in 6-8 wks
- Ophthalmology f/u
- If aneurysm/mass
- Neurosurgery consult
- If diplopia, no driving or operating heavy machinery
Source
Harwood and Nuss, Rosen's, Emedicine