Third nerve palsy: Difference between revisions
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== Background == | == Background == | ||
*Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique) | *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 Aneurysm | *Posterior Communicating Artery Aneurysm | ||
**Compresses nerve | **Compresses nerve | ||
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*Trauma | *Trauma | ||
**Temporal lobe herniation through tentorium | **Temporal lobe 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 defecits | **often associated with other cranial nerve defecits | ||
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*Autoimmune vasculitis ([[Systemic Lupus Erythematosus|Lupus]]) | *Autoimmune vasculitis ([[Systemic Lupus Erythematosus|Lupus]]) | ||
== Clinical Features | == Clinical Features== | ||
*Eye deviates laterally and down | *Eye deviates laterally and down | ||
*Pupil exam: | *Pupil exam: | ||
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== DDx == | == DDx == | ||
*Aneurysm <ref>Chaudhary,N. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. J. Neuro-Ophthalmol 2009;29:238-244</ref> | |||
*Aneurysm | |||
*Carotid Cavernous Fistula | *Carotid Cavernous Fistula | ||
*Mass | *Mass | ||
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== Sources == | == Sources == | ||
<references/> | |||
[[Category:Ophtho]] [[Category:Neuro]] | [[Category:Ophtho]] [[Category:Neuro]] | ||
Revision as of 20:20, 21 December 2014
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 Aneurysm
- Compresses nerve
- Ischemia
- Diabetes
- Trauma
- Temporal lobe herniation through tentorium
- Myasthenia Gravis[2]
- 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 [3]
- 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
Sources
- ↑ 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