Download PDF
Semin Neurol 2007; 27(3): 257-268
DOI: 10.1055/s-2007-979681
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Third Nerve Palsies

Beau B. Bruce1 , Valérie Biousse1 , 2 , Nancy J. Newman1 , 2 , 3
  • 1Department of Ophthalmology Surgery, Emory University School of Medicine, Atlanta, Georgia
  • 2Department of Neurology Surgery, Emory University School of Medicine, Atlanta, Georgia
  • 3Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
Further Information

Publication History

Publication Date:
18 June 2007 (online)

    Permissions and Reprints

ABSTRACT

The diagnosis and management of third nerve dysfunction vary according to the age of the patient, the characteristics of the third nerve palsy, and the presence of associated symptoms and signs. Third nerve palsies can result from lesions located anywhere from the oculomotor nucleus to the termination of the third nerve in the extraocular muscles within the orbit, and may be the herald manifestation of underlying neurological emergencies such as intracranial aneurysm, pituitary apoplexy, and giant cell arteritis. Recent advances in noninvasive neuroimaging facilitate early diagnosis, but the management of a patient presenting with isolated third nerve palsy remains a challenge.

KEYWORDS

Oculomotor nerve - third nerve - diplopia

REFERENCES

  • 1 Burde R M, Loewy A D. Central origin of oculomotor parasympathetic neurons in the monkey.  Brain Res. 1980;  198 434-439
    CrossrefPubMedGoogle Scholar
  • 2 Miller NR, Newman NJ, Biousse V, Kerrison JB Walsh and Hoyt's Clinical Neuro-Ophthalmology. 6th ed. Philadelphia; Lippincott Williams & Wilkins 2005
    Google Scholar
  • 3 Burde R M, Savino P J, Trobe J D. Clinical Decisions in Neuro-Ophthalmology. St. Louis; Mosby 1985: 184-185
    Google Scholar
  • 4 Biller J, Shapiro R, Evans L S, Haag J R, Fine M. Oculomotor nuclear complex infarction: clinical and radiological correlation.  Arch Neurol. 1984;  41 985-987
    PubMedGoogle Scholar
  • 5 Bryan J S, Hamed L M. Levator-sparing nuclear oculomotor palsy: clinical and magnetic resonance imaging findings.  J Clin Neuroophthalmol. 1992;  12 26-30
    PubMedGoogle Scholar
  • 6 Martin T J, Corbett J J, Babikian P V, Crawford S C, Currier R D. Bilateral ptosis due to mesencephalic lesions with relative preservation of ocular motility.  J Neuroophthalmol. 1996;  16 258-263
    PubMedGoogle Scholar
  • 7 Caplan L R. “Top of the basilar” syndrome.  Neurology. 1980;  30 72-79
    CrossrefPubMedGoogle Scholar
  • 8 Liu G T, Crenner C W, Logigian E L, Charness M E, Samuels M A. Midbrain syndromes of Benedikt, Claude, and Nothnagel: setting the record straight.  Neurology. 1992;  42 1820-1822
    PubMedGoogle Scholar
  • 9 Nothnagel H. Topische Diagnostik der Gehirnkrankheiten. Eine Klinische Studie. Berlin; A. Hirschwald 1879
    Google Scholar
  • 10 Seo S W, Heo J H, Lee K Y et al.. Localization of Claude's syndrome.  Neurology. 2001;  57 2304-2307
    PubMedGoogle Scholar
  • 11 Weber H D. A contribution to the pathology of the crura cerebri.  Medico Chirurg Trans. 1863;  46 121-139
    PubMedGoogle Scholar
  • 12 Neetens A, Selosse P. Oculomotor anomalies in sellar and parasellar pathology.  Ophthalmologica. 1977;  175 80-104
    PubMedGoogle Scholar
  • 13 Trobe J D, Glaser J S, Post J D. Meningiomas and aneurysms of the cavernous sinus: neuro-ophthalmologic features.  Arch Ophthalmol. 1978;  96 457-467
    PubMedGoogle Scholar
  • 14 Jefferson G. The Bowman Lecture: concerning injuries, aneurysms and tumors involving the cavernous sinus.  Trans Ophthalmol Soc U K. 1953;  73 117-152
    PubMedGoogle Scholar
  • 15 Thomas J E, Yoss R E. The parasellar syndrome: problems in determining etiology.  Mayo Clin Proc. 1970;  45 617-623
    PubMedGoogle Scholar
  • 16 Hollenhorst R W, Younge B R. Ocular manifestations produced by adenomas of the pituitary gland: analysis of 1000 cases. In: Kohler PO, Ross GT Diagnosis and Treatment of Pituitary Tumors. Vol. 303. New York; Elsevier 1973: 53-64
    Google Scholar
  • 17 Weinberger L M, Adler F H, Grant F C. Primary pituitary adenoma and the syndrome of the cavernous sinus: a clinical and anatomic study.  Arch Ophthalmol. 1940;  14 1197-1235
    PubMedGoogle Scholar
  • 18 Robert Jr C M, Feigenbaum J A, Stern E W. Ocular palsy occurring with pituitary tumors.  J Neurosurg. 1973;  38 17-19
    PubMedGoogle Scholar
  • 19 Bills D C, Meyer F B, Laws Jr E R et al.. A retrospective analysis of pituitary apoplexy.  Neurosurgery. 1993;  33 602-608 discussion 608-609
    CrossrefPubMedGoogle Scholar
  • 20 Rovit R L, Fein J M. Pituitary apoplexy: a review and reappraisal.  J Neurosurg. 1972;  37 280-288
    PubMedGoogle Scholar
  • 21 Wakai S, Fukushima T, Teramoto A, Sano K. Pituitary apoplexy: its incidence and clinical significance.  J Neurosurg. 1981;  55 187-193
    CrossrefPubMedGoogle Scholar
  • 22 Bonicki W, Kasperlik-Zaluska A, Koszewski W, Zgliczynski W, Wislawski J. Pituitary apoplexy-endocrine, surgical and oncological emergency: incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas.  Acta Neurochir (Wien). 1993;  120 118-122
    CrossrefPubMedGoogle Scholar
  • 23 McFadzean R M, Doyle D, Rampling R, Teasdale E, Teasdale G. Pituitary apoplexy and its effect on vision.  Neurosurgery. 1991;  29 669-675
    CrossrefPubMedGoogle Scholar
  • 24 Meadows S P. Intracavernous aneurysms of the internal carotid artery: their clinical features and natural history.  Arch Ophthalmol. 1959;  62 566-574
    PubMedGoogle Scholar
  • 25 Kline L B. The Tolosa-Hunt syndrome.  Surv Ophthalmol. 1982;  27 79-95
    CrossrefPubMedGoogle Scholar
  • 26 Keane J R. Cavernous sinus syndrome: analysis of 151 cases.  Arch Neurol. 1996;  53 967-971
    PubMedGoogle Scholar
  • 27 Biousse V, Newman N J. Aneurysms and subarachnoid hemorrhage.  Neurosurg Clin N Am. 1999;  10 631-651
    PubMedGoogle Scholar
  • 28 Biousse V, Mendicino M E, Simon D J, Newman N J. The ophthalmology of intracranial vascular abnormalities.  Am J Ophthalmol. 1998;  125 527-544
    CrossrefPubMedGoogle Scholar
  • 29 Stiebel-Kalish H, Kalish Y, Bar-On R H et al.. Presentation, natural history, and management of carotid cavernous aneurysms.  Neurosurgery. 2005;  57 850-857 discussion 850-857
    CrossrefPubMedGoogle Scholar
  • 30 Ebright J R, Pace M T, Niazi A F. Septic thrombosis of the cavernous sinuses.  Arch Intern Med. 2001;  161 2671-2676
    CrossrefPubMedGoogle Scholar
  • 31 Archambault P, Wise J S, Rosen J, Polomeno R C, Auger N. Herpes zoster ophthalmoplegia: report of six cases.  J Clin Neuroophthalmol. 1988;  8 185-193
    PubMedGoogle Scholar
  • 32 Hunt W E. Tolosa-Hunt syndrome: one cause of painful ophthalmoplegia.  J Neurosurg. 1976;  44 544-549
    PubMedGoogle Scholar
  • 33 Hunt W E, Brightman R P. The Tolosa-Hunt syndrome: a problem in differential diagnosis.  Acta Neurochir Suppl (Wien). 1988;  42 248-252
    PubMedGoogle Scholar
  • 34 Hunt W E, Meagher J N, Lefever H E, Zeman W. Painful ophthalmoplegia: its relation to indolent inflammation of the cavernous sinus.  Neurology. 1961;  11 56-62
    CrossrefPubMedGoogle Scholar
  • 35 La Mantia L, Curone M, Rapoport A M, Bussone G. Tolosa-Hunt syndrome: critical literature review based on IHS 2004 criteria.  Cephalalgia. 2006;  26 772-781
    CrossrefPubMedGoogle Scholar
  • 36 Fisher M. An unusual variant of acute idiopathic polyneuritis (syndrome of ophthalmoplegia, ataxia and areflexia).  N Engl J Med. 1956;  255 57-65
    CrossrefPubMedGoogle Scholar
  • 37 Yuki N, Odaka M, Hirata K. Acute ophthalmoparesis (without ataxia) associated with anti-GQ1b IgG antibody: clinical features.  Ophthalmology. 2001;  108 196-200
    CrossrefPubMedGoogle Scholar
  • 38 Clouston P D, Sharpe D M, Corbett A J, Kos S, Kennedy P J. Perineural spread of cutaneous head and neck cancer: its orbital and central neurologic complications.  Arch Neurol. 1990;  47 73-77
    CrossrefPubMedGoogle Scholar
  • 39 Nogajski J H, Brewer J, Storey C E. Perineural spread of facial squamous cell carcinoma.  J Clin Neurosci. 2006;  13 400-403
    CrossrefPubMedGoogle Scholar
  • 40 Williams L S, Mancuso A A, Mendenhall W M. Perineural spread of cutaneous squamous and basal cell carcinoma: CT and MR detection and its impact on patient management and prognosis.  Int J Radiat Oncol Biol Phys. 2001;  49 1061-1069
    CrossrefPubMedGoogle Scholar
  • 41 Dhaliwal A, West A L, Trobe J D, Musch D C. Third, fourth, and sixth cranial nerve palsies following closed head injury.  J Neuroophthalmol. 2006;  26 4-10
    CrossrefPubMedGoogle Scholar
  • 42 Levy R L, Geist C E, Miller N R. Isolated oculomotor palsy following minor head trauma.  Neurology. 2005;  65 169
    CrossrefPubMedGoogle Scholar
  • 43 Trobe J D. Isolated pupil-sparing third nerve palsy.  Ophthalmology. 1985;  92 58-61
    PubMedGoogle Scholar
  • 44 Trobe J D. Third nerve palsy and the pupil: footnotes to the rule.  Arch Ophthalmol. 1988;  106 601-602
    CrossrefPubMedGoogle Scholar
  • 45 Trobe J D. Managing oculomotor nerve palsy.  Arch Ophthalmol. 1998;  116 798
    CrossrefPubMedGoogle Scholar
  • 46 Kupersmith M J, Heller G, Cox T A. Magnetic resonance angiography and clinical evaluation of third nerve palsies and posterior communicating artery aneurysms.  J Neurosurg. 2006;  105 228-234
    PubMedGoogle Scholar
  • 47 Asbury A K, Aldredge H, Hershberg R, Fisher C M. Oculomotor palsy in diabetes mellitus: a clinico-pathological study.  Brain. 1970;  93 555-566
    CrossrefPubMedGoogle Scholar
  • 48 Bortolami R, D'Alessandro R, Manni E. The origin of pain in “ischemic-diabetic” third-nerve palsy.  Arch Neurol. 1993;  50 795
    PubMedGoogle Scholar
  • 49 Capo H, Warren F, Kupersmith M J. Evolution of oculomotor nerve palsies.  J Clin Neuroophthalmol. 1992;  12 21-25
    PubMedGoogle Scholar
  • 50 Lustbader J M, Miller N R. Painless, pupil-sparing but otherwise complete oculomotor nerve paresis caused by basilar artery aneurysm: case report.  Arch Ophthalmol. 1988;  106 583-584
    PubMedGoogle Scholar
  • 51 Kasoff I, Kelly Jr D L. Pupillary sparing in oculomotor palsy from internal carotid aneurysm: case report.  J Neurosurg. 1975;  42 713-717
    PubMedGoogle Scholar
  • 52 O'Connor P S, Tredici T J, Green R P. Pupil-sparing third nerve palsies caused by aneurysm.  Am J Ophthalmol. 1983;  95 395-397
    PubMedGoogle Scholar
  • 53 Kissel J T, Burde R M, Klingele T G, Zeiger H E. Pupil-sparing oculomotor palsies with internal carotid-posterior communicating artery aneurysms.  Ann Neurol. 1983;  13 149-154
    CrossrefPubMedGoogle Scholar
  • 54 Rucker C W. Paralysis of the third, fourth and sixth cranial nerves.  Am J Ophthalmol. 1958;  46 787-794
    CrossrefPubMedGoogle Scholar
  • 55 Rush J A, Younge B R. Paralysis of cranial nerves III, IV, and VI: cause and prognosis in 1,000 cases.  Arch Ophthalmol. 1981;  99 76-79
    CrossrefPubMedGoogle Scholar
  • 56 Goldstein J E, Cogan D G. Diabetic ophthalmoplegia with special reference to the pupil.  Arch Ophthalmol. 1960;  64 592-600
    PubMedGoogle Scholar
  • 57 Jacobson D M. Pupil involvement in patients with diabetes-associated oculomotor nerve palsy.  Arch Ophthalmol. 1998;  116 723-727
    CrossrefPubMedGoogle Scholar
  • 58 Thomas J E, Waltz A G. Neurological manifestations of nasopharyngeal malignant tumors.  JAMA. 1965;  192 95-98
    PubMedGoogle Scholar
  • 59 Hopf H C, Gutmann L. Diabetic 3rd nerve palsy: evidence for a mesencephalic lesion.  Neurology. 1990;  40 1041-1045
    PubMedGoogle Scholar
  • 60 Eggenberger E R, Miller N R, Hoffman P N, Nauta H J, Green W R. Mesencephalic ependymal cyst causing an inferior divisional paresis of the oculomotor nerve: case report.  Neurology. 1993;  43 2419-2420
    PubMedGoogle Scholar
  • 61 Ksiazek S M, Slamovits T L, Rosen C E, Burde R M, Parisi F. Fascicular arrangement in partial oculomotor paresis.  Am J Ophthalmol. 1994;  118 97-103
    PubMedGoogle Scholar
  • 62 Schwartz T H, Lycette C A, Yoon S S, Kargman D E. Clinicoradiographic evidence for oculomotor fascicular anatomy.  J Neurol Neurosurg Psychiatry. 1995;  59 338
    PubMedGoogle Scholar
  • 63 Headache Classification Subcommitte of the International Headache Society . The International Classification of Headache Disorders: 2nd ed.  Cephalalgia. 2004;  24(suppl 1) 9-160
    CrossrefPubMedGoogle Scholar
  • 64 Biousse V, Touboul P J, D'Anglejan-Chatillon J, Levy C, Schaison M, Bousser M G. Ophthalmologic manifestations of internal carotid artery dissection.  Am J Ophthalmol. 1998;  126 565-577
    CrossrefPubMedGoogle Scholar
  • 65 Campos C R, Massaro A R, Scaff M. Isolated oculomotor nerve palsy in spontaneous internal carotid artery dissection: case report.  Arq Neuropsiquiatr. 2003;  61 668-670
    CrossrefPubMedGoogle Scholar
  • 66 Hollinger P, Sturzenegger M. Painful oculomotor nerve palsy: a presenting sign of internal carotid artery stenosis.  Cerebrovasc Dis. 1999;  9 178-181
    CrossrefPubMedGoogle Scholar
  • 67 Mahagne M H, Dunac A, Bedoucha P, Chatel M. Isolated ischemic third-nerve palsy as a warning sign of severe internal carotid artery stenosis.  Cerebrovasc Dis. 2002;  14 264-265
    CrossrefPubMedGoogle Scholar
  • 68 Thömke F, Ringel K, Schindler H, Hopf H C. Pupil-sparing oculomotor palsy as the only clinical sign of an internal carotid artery occlusion.  Eur J Neurol. 1999;  6 378
    CrossrefPubMedGoogle Scholar
  • 69 Ksiazek S M, Repka M X, Maguire A et al.. Divisional oculomotor nerve paresis caused by intrinsic brainstem disease.  Ann Neurol. 1989;  26 714-718
    CrossrefPubMedGoogle Scholar
  • 70 Miller N R. Solitary oculomotor nerve palsy in childhood.  Am J Ophthalmol. 1977;  83 106-111
    PubMedGoogle Scholar
  • 71 Balkan R, Hoyt C S. Associated neurologic abnormalities in congenital third nerve palsies.  Am J Ophthalmol. 1984;  97 315-319
    CrossrefPubMedGoogle Scholar
  • 72 Hamed L M. Associated neurologic and ophthalmologic findings in congenital oculomotor nerve palsy.  Ophthalmology. 1991;  98 708-714
    CrossrefPubMedGoogle Scholar
  • 73 Wilhelm H, Wilhelm B, Mildenberger I. Primary aberrant regeneration of abducens nerve fibers into the pupillary pathway.  Neuroophthalmology. 1994;  14 85-89
    PubMedGoogle Scholar
  • 74 Lepore F E, Glaser J S. Misdirection revisited: a critical appraisal of acquired oculomotor nerve synkinesis.  Arch Ophthalmol. 1980;  98 2206-2209
    CrossrefPubMedGoogle Scholar
  • 75 Ezra E, Spalton D, Sanders M D, Graham E M, Plant G T. Ocular neuromyotonia.  Br J Ophthalmol. 1996;  80 350-355
    CrossrefPubMedGoogle Scholar
  • 76 Jacob M, Vighetto A, Bernard M, Tilikete C. Ocular neuromyotonia secondary to a cavernous sinus meningioma.  Neurology. 2006;  66 1598-1599
    CrossrefPubMedGoogle Scholar
  • 77 Miller N R, Lee A G. Adult-onset acquired oculomotor nerve paresis with cyclic spasms: relationship to ocular neuromyotonia.  Am J Ophthalmol. 2004;  137 70-76
    CrossrefPubMedGoogle Scholar
  • 78 Lee A G, Hayman L A, Brazis P W. The evaluation of isolated third nerve palsy revisited: an update on the evolving role of magnetic resonance, computed tomography, and catheter angiography.  Surv Ophthalmol. 2002;  47 137-157
    CrossrefPubMedGoogle Scholar
  • 79 Jacobson D M, Trobe J D. The emerging role of magnetic resonance angiography in the management of patients with third cranial nerve palsy.  Am J Ophthalmol. 1999;  128 94-96
    CrossrefPubMedGoogle Scholar
  • 80 Vanninen R L, Hernesniemi J A, Puranen M I, Ronkainen A. Magnetic resonance angiographic screening for asymptomatic intracranial aneurysms-the problem of false negatives: technical case report.  Neurosurgery. 1996;  38 838-840 discussion 840-831
    PubMedGoogle Scholar
  • 81 Wilcock D, Jaspan T, Holland I, Cherryman G, Worthington B. Comparison of magnetic resonance angiography with conventional angiography in the detection of intracranial aneurysms in patients presenting with subarachnoid haemorrhage.  Clin Radiol. 1996;  51 330-334
    CrossrefPubMedGoogle Scholar
  • 82 Gabianelli E B, Klingele T G, Burde R M. Acute oculomotor nerve palsy in childhood: is arteriography necessary?.  J Clin Neuroophthalmol. 1989;  9 33-36
    PubMedGoogle Scholar
  • 83 Branley M G, Wright K W, Borchert M S. Third nerve palsy due to cerebral artery aneurysm in a child.  Aust N Z J Ophthalmol. 1992;  20 137-140
    PubMedGoogle Scholar
  • 84 Ng Y S, Lyons C J. Oculomotor nerve palsy in childhood.  Can J Ophthalmol. 2005;  40 645-653
    CrossrefPubMedGoogle Scholar
  • 85 Abdul-Rahim A S, Savino P J, Zimmerman R A, Sergott R C, Bosley T M. Cryptogenic oculomotor nerve palsy: the need for repeated neuroimaging studies.  Arch Ophthalmol. 1989;  107 387-390
    PubMedGoogle Scholar
  • 86 Hamer J. Prognosis of oculomotor palsy in patients with aneurysms of the posterior communicating artery.  Acta Neurochir (Wien). 1982;  66 173-185
    CrossrefPubMedGoogle Scholar

Valérie BiousseM.D. 

Neuro-Ophthalmology Unit, Emory Eye Center

1365-B Clifton Road NE, Atlanta, GA 30322

      >