Third Nerve Palsy: Analysis of 1400 Personally-examined Inpatients

Abstract

Third nerve palsy (TNP) may be difficult to diagnose, the causes are often elusive, the prognosis is potentially catastrophic, and the optimal workup is currently in flux. The landmark large study of TNP is composed of four sequential articles on ocular motor nerve palsies, each describing ten years experience at the Mayo Clinic [1][2][3][4] . That survey and most other studies of TNP 5-11 (Table 1) are based largely upon referral patients seen by many different doctors with only several having even a token experience with magnetic resonance imaging (MRI). The present study explores the causes and sites of TNP in a large contrasting group of municipal hospital inpatients examined by a single neuro-ophthalmologist. ABSTRACT:Background: Most studies of third nerve palsy (TNP) antedate computerized imaging and focus primarily on chart review of referral outpatients. Methods: To compare a large contrasting population, I reviewed 1400 personally-examined municipal hospital inpatients with TNPs seen over 37 years. Results: TNPs were bilateral in 11%, complete in 33%, without other neurological signs (isolated) in 36%, and associated with recurrent cranial neuropathies in 7%. Third nerve damage occurred in the subarachnoid space in 32%, the cavernous sinus in 23%, the brainstem in 14%, as a nonlocalized peripheral neuropathy in 18% and at an uncertain location in 13%. Causes were trauma (26%), tumor (12%), diabetes (11%), aneurysm (10%), surgery (10%), stroke (8%), infection (5%), Guillain-Barre and Fisher syndromes (5%), idiopathic cavernous sinusitis (3%), benign self-limited (2%), miscellaneous (4%), and unknown (3%). Local causes, besides an abundance of trauma, included six cases involving cysticercosis, four with wound botulism, and one with coccidiomycotic meningitis. Of 234 patients with diabetes, microvascular ischemia was the cause of TNP in only two-thirds (five had aneurysms) and 53% of those with diabetic microvascular ischemia had pupillary involvement-often bilateral, suggesting concomitant autonomic neuropathy. Only 2% of aneurysms spared the pupil. A painful onset occurred with 94% of aneurysm and 69% of diabetic cases. Conclusions: Bilateral TNPs, multiple cranial neuropathies, and accompanying neurological signs were common among our inpatients, as were causes rare in outpatient settings such as severe trauma, transtentorial herniation, midbrain strokes, and the Guillain-Barre syndrome. Few cases remained undiagnosed and nondiabetic ischemia was rare.RÉSUMÉ: Paralysie du troisième nerf : analyse de 1400 patients hospitalisés examinés par le même observateur. Contexte : La plupart des études sur la paralysie du troisième nerf (PTN) sont antérieures à la tomodensitométrie et sont constituées principalement de revues de dossiers de patients externes. Méthodes : Afin d'examiner un volet différent de la PTN, j'ai révisé 1400 dossiers de patients atteints d'une PTN, hospitalisés dans un hôpital municipal, que j'ai moi-même examinés au cours d'une période de 37 ans. Résultats : La PTN était bilatérale chez ...

Acquired Ocular Motor Nerve Palsy in Neurology Clinics: A Prospective Multicenter Study

“…Our results are consistent with previous studies also finding no difference in the degree of external ophthalmoplegia and pupillary involvement between cranial third-nerve palsies due to microvascular ischemia and other etiologies 719. Indeed, approximately one-third of patients with cranial third-nerve palsy due to microvascular ischemia are known to show some degree of pupillary involvement 62425…”

Acquired Ocular Motor Nerve Palsy in Neurology Clinics: A Prospective Multicenter Study

“…Our results are consistent with previous studies also finding no difference in the degree of external ophthalmoplegia and pupillary involvement between cranial third-nerve palsies due to microvascular ischemia and other etiologies 719. Indeed, approximately one-third of patients with cranial third-nerve palsy due to microvascular ischemia are known to show some degree of pupillary involvement 62425…”

Etiological distribution of isolated oculomotor nerve palsy: analysis of 633 patients and literature review

“…As in most of the previous studies (23.8%–63.5%) [3, 4, 6, 10, 12–16], microvascular was the most common etiology of isolated oculomotor nerve palsy in this study (26.5%), especially in men (34.6%). In contrast, vascular anomalies were the most common in women (27.1%).…”

“…As in most of the previous studies (23.8%-63.5%) [3,4,6,10,[12][13][14][15][16], microvascular was the most common etiology of isolated…”

Oculomotor Nerve Palsy—Etiologies, Symptoms and Diagnosis: A Systematic Review with Meta-Analysis

“…This symptom describes unilateral periorbital pain or headache ipsilateral to the nerve palsy. While intense pain is often considered associated with aneurysmal expansion or rupture, our findings and supporting literature indicate that pain is also remarkably common in ischemic cases or diabetic or hypertensive OMNP [ 10 , 21 ].…”

Acquired Ocular Motor Nerve Palsy in Neurology Clinics: A Prospective Multicenter Study

“…Our results are consistent with previous studies also finding no difference in the degree of external ophthalmoplegia and pupillary involvement between cranial third-nerve palsies due to microvascular ischemia and other etiologies 719. Indeed, approximately one-third of patients with cranial third-nerve palsy due to microvascular ischemia are known to show some degree of pupillary involvement 62425…”

Etiological distribution of isolated oculomotor nerve palsy: analysis of 633 patients and literature review

“…As in most of the previous studies (23.8%–63.5%) [3, 4, 6, 10, 12–16], microvascular was the most common etiology of isolated oculomotor nerve palsy in this study (26.5%), especially in men (34.6%). In contrast, vascular anomalies were the most common in women (27.1%).…”

“…As in most of the previous studies (23.8%-63.5%) [3,4,6,10,[12][13][14][15][16], microvascular was the most common etiology of isolated…”

Oculomotor Nerve Palsy—Etiologies, Symptoms and Diagnosis: A Systematic Review with Meta-Analysis

“…This symptom describes unilateral periorbital pain or headache ipsilateral to the nerve palsy. While intense pain is often considered associated with aneurysmal expansion or rupture, our findings and supporting literature indicate that pain is also remarkably common in ischemic cases or diabetic or hypertensive OMNP [ 10 , 21 ].…”

Acquired Ocular Motor Nerve Palsy in Neurology Clinics: A Prospective Multicenter Study

“…Our results are consistent with previous studies also finding no difference in the degree of external ophthalmoplegia and pupillary involvement between cranial third-nerve palsies due to microvascular ischemia and other etiologies 719. Indeed, approximately one-third of patients with cranial third-nerve palsy due to microvascular ischemia are known to show some degree of pupillary involvement 62425…”

Etiological distribution of isolated oculomotor nerve palsy: analysis of 633 patients and literature review

“…As in most of the previous studies (23.8%–63.5%) [3, 4, 6, 10, 12–16], microvascular was the most common etiology of isolated oculomotor nerve palsy in this study (26.5%), especially in men (34.6%). In contrast, vascular anomalies were the most common in women (27.1%).…”

“…As in most of the previous studies (23.8%-63.5%) [3,4,6,10,[12][13][14][15][16], microvascular was the most common etiology of isolated…”

Oculomotor Nerve Palsy—Etiologies, Symptoms and Diagnosis: A Systematic Review with Meta-Analysis

“…This symptom describes unilateral periorbital pain or headache ipsilateral to the nerve palsy. While intense pain is often considered associated with aneurysmal expansion or rupture, our findings and supporting literature indicate that pain is also remarkably common in ischemic cases or diabetic or hypertensive OMNP [ 10 , 21 ].…”