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) <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> | *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 | ||
*Ischemia | *Ischemia | ||
**Diabetes | **[[Diabetes]] | ||
*Trauma | *Trauma | ||
**Temporal lobe herniation through tentorium | **Temporal lobe herniation through tentorium | ||
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*Loss of accommodation | *Loss of accommodation | ||
== | ==Differential Diagnosis== | ||
*Aneurysm <ref>Chaudhary,N. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. J. Neuro-Ophthalmol 2009;29:238-244</ref> | *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 | *Carotid Cavernous Fistula | ||
*Mass | *Mass | ||
*Ischemia | *Ischemia | ||
*Myasthenia | *[[Myasthenia gravis]] | ||
*Thyroid associated orbitopathy | *Thyroid associated orbitopathy | ||
*Internuclear opthalmoplegia | *Internuclear opthalmoplegia | ||
*Giant | *[[Giant cell arteritis]] | ||
== Work-up == | == Work-up == | ||
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:CTA brain followed by MRI/MRA brain | :CTA brain followed by MRI/MRA brain | ||
== | == Disposition == | ||
*If ischemic cause | *If ischemic cause | ||
**Medical management with most self resolving in 6-8 wks | **Medical management with most self resolving in 6-8 wks | ||
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*If aneurysm/mass | *If aneurysm/mass | ||
**Neurosurgery consult | **Neurosurgery consult | ||
*If diplopia, no driving or operating heavy machinery | *If [[diplopia]], no driving or operating heavy machinery | ||
==See Also== | |||
*[[Cranial nerves]] | |||
== Sources == | == Sources == | ||
<references/> | <references/> | ||
[[Category:Ophtho]] | [[Category:Ophtho]] | ||
[[Category:Neuro]] | [[Category:Neuro]] | ||
Revision as of 08:17, 22 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
- 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
Differential Diagnosis
- 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
Disposition
- 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
See Also
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