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A Cliniconeuroradiologic Approach to Third Cranial Nerve Palsies

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A Cliniconeuroradiologic Approach to Third Cranial Nerve Palsies 459 A Cliniconeuroradiologic Approach to Third Cranial Nerve Palsies Eddie S. K. Kwan 1 Sixty-three patients with third cranial nerve palsies (CNPs), either isolated (31) or in Michael Laucella 1 association with other neurologic deficits (32), underwent neuroophthalmologic and Thomas R. Hedges 1112 neuroradiologic evaluation. Discrepancies between the clinical and radiologic evalua­ Samuel M. Wolpert1 tions were analyzed and useful clinical presenting symptoms were identified. Microvas­ cular infarction secondary to diabetes mellitus and/or hypertension was the most common cause in patients with isolated third CNP, and extensive neuroradiologic evaluation is not indicated in this subgroup. The overall diagnostic yield of high­ resolution CT for isolated third CNPs was low (30%), but improved to 60% if diabetes and hypertension were excluded. However, CT was highly sensitive (90%) in those patients with third CNPs associated with additional neurologic deficits. The status of the pupil in and of itself cannot be the sole determinant as to whether angiography is indicated to exclude an aneurysm. Careful ophthalmologic observation and relating the severity of pupillomotor dysfunction to extraocular ophthalmoplegia is mandatory to determine the logical sequence of radiologic evaluation. Retroorbital pain taken in isolation is a nonspecific presenting symptom and has differential diagnostic value only if it is correlated temporally with the onset of third CNP and the presence or absence of additional cranial nerve deficits. Distinguishing patients with third cranial nerve palsy (CNP) secondary to ischemic microvascular disease from those with structural lesions in the brainstem, circle of Willis, cavernous sinus, and orbital apex is a common clinical problem . In patients with ischemic third CNP extensive radiologic evaluation is not indicated in view of the high prevalence of diabetes mellitus, the most common cause of such lesions. The palsies can be broadly divided into those with external (extraocular ophthal­ moplegia) and those with internal (pupillary) dysfunction; the degree of involvement in each can vary from partial to complete. While the majority of isolated third CNPs with pupil sparing are due to diabetes and those with pupil involvement are due to expanding posterior communicating artery aneurysms, atypical cases from either cause can overlap and mimic each other. Fortunately careful clinical neuroophthal­ mologic examination can , in most cases , distinguish between ischemic and struc­ tural third CNPs. The roles of CT in the evaluation of cavernous sinus/orbital lesions [1-4] and carotid angiography in the evaluation of posterior communicating artery (PCA) aneurysm are well established [5]. However, we are unaware of any report devoted Received June 27. 1986; accepted after revision exclusively to studying the efficacy of current neuroradiologic techniques in the November 28, 1986. evaluation of patients with third CNP and comparing these studies with the efficacy 1 Department of Radiology, New England Medi­ of clinical evaluation. In this article the discrepancies between the clinical and cal Center Hospitals, 171 Harrison Ave ., Box 88, Boston, MA 02111 . Address reprint requests to E. radiologic evaluations of 63 patients with third CNPs are analyzed and an algorithm S. K. Kwan . based on this analysis is presented. 2 Section of Neuroophthalmology. New England Medical Center Hospitals, Boston, MA 02111 . AJNR 8:459-468, May/June 1987 Anatomy 0195-6108/87/0803-0459 © American Society of Neuroradiology The nucleus of the oculomotor nerve consists of an elongated mass of cells lying 460 KWAN ET AL. AJNR:8, May/June 1987 in the inferior periaqueductal gray matter of the mesenceph­ Materials and Methods alon . In addition to motor neurons, the oculomotor nucleus From October 1981 to April 1986, 73 patients were evaluated by contains cells whose axon projects as preganglionic, para­ the neuroophthalmology department at New England Medical Center sympathetic fibers to the ciliary ganglion for control of pupillary Hospitals for suspected third CNPs. Sixty-three of these patients constriction and accommodation. From the ventral aspect of underwent neuroradiologic evaluation (62 patients had CT, 30 had the oculomotor nucleus, axonal fibers traverse between the angiography, and four had MR). The clinical and neuroradiologic red nucleus and substantia nigra to exit the brainstem through evaluation of the 63 patients is the subject of this report. After the interpeduncular fossa [6). The cisternal segment of the reviewing the clinical presentation with the referring neuroophthal­ oculomotor nerve then passes between the peduncular seg­ mologist, we determined a tailored sequence of radiologic evaluation ment of the posterior cerebral artery and the superior cere­ depending on whether the orbit, parasellar region , supratentorial bellar artery, inferolateral to the PCA and medial to the free region , or brainstem area was suspected of being involved. All patients were scanned with a modern CT scanner (Siemens Soma­ edge of the tentorium (Fig . 1). Pupilloconstrictor fibers are tom II or DR3). Cerebral angiograms were all obtained selectively located superficially along the dorsomedial portion of the with magnification techniques. MR scans were obtained on a 1-T unit nerve, accounting for its high frequency of involvement in the (Siemens Magnetom). Spin-echo (SE) sequences were performed presence of an expanding PCA aneurysm. The vascular sup­ with several different repetition (TR) and echo delay (TE) times. The ply of the third nerve in the subarachnoid space and the final diagnosis was based on either clinical follow-up, response to cavernous sinus includes branches originating from the prox­ appropriate therapy, surgery, or unequivocal radiologic findings. imal segment of the posterior cerebral artery, dorsal menin­ geal and inferior hypophyseal branches of the meningohypo­ physeal trunk, and the recurrent branch of the ophthalmic Results artery. Within the cavernous sinus, the third nerve is located The 63 patients were subdivided into six categories on the superior to the trochlear, abducens, and the first two divisions basis of clinical presentations (Tables 1 and 2): category 1- of the trigeminal nerves. The third nerve divides into two complete external third CNP with pupil sparing (17 patients); trunks after entering the orbit via the superior orbital fissure. category 2-complete external third CNP with partial pupil The superior trunk innervates the superior rectus and the involvement/relative pupil sparing third CNP (two patients); levator palpebrae superioris. The inferior trunk innervates the category 3-partial external third CNP with partial pupil in­ medial rectus, inferior rectus, and inferior oblique muscles; it volvement (three patients); category 4-complete external also transmits preganglionic parasympathetic fibers to the and internal third CNP (11 patients); category 5-complete pupil by way of the ciliary ganglion. Sympathetic pupillary external third CNP (with or without pupil involvement) and fibers from the superior cervical ganglion ascend with the additional cranial nerve dysfunction (16 patients); and cate­ internal carotid artery and joins the ophthalmic division of the gory 6-complete external and internal third CNP with addi­ fifth nerve to reach the iris. tional neurologic deficits (14 patients). I Posterior '" communicOiting ...........---ICA utery Posterior ~----- P. CO. A. cerebral artery III IV Recurrent ........--PCA Superior ~~;:2!:~~ collateral cerebellu brOinches f"'o,.i""""'"*-SCA artery Basilar artery Meningohypophyseal trunk Fig. 1.-Vascular supply of cisternal segment of third (III) cranial nerve and its relationship to posterior communicating artery. OC = optic chiasm; PG =pituitary gland; ICA =cavernous internal carotid artery; OMB =dorsal meningeal branch of men in go hypophyseal trunk; Inf. = inferior; ON =optic nerve; In. =infundibulum; P. Co. A. =posterior communicating artery; PCA =posterior cerebral artery; SCA =superior cerebellar artery; CP =cerebral peduncle; SN =substantia nigra; RN = red nucleus; A = aqueduct. AJNR :8, May/June 1987 THIRD CRANIAL NERVE PALSIES 461 TABLE 1: Final Diagnoses in Patients with Third Cranial Nerve Category 1 Palsies All 17 patients with complete external third CNP with pupil No . of Category: Final Diagnosis sparing had high-resolution, 2-mm, axi al , contrast-enhanced Patients CT through the circle of Willis and cavernous sinus. The scans 1. Complete external third CNP with pupil were all negative except for two patients: a patient with sparing: Ischemic third CNP 14 myasthenia gravis and an incidental aneurysm at the pedun­ Ophthalmic migraine 1 cular segment of the posterior cerebral artery (Fig. 2) contra­ Myasthenia gravis 1 lateral to the ptOSis and retroorbital pain , and a patient with Idiopathic third CNP 1 incidental bilateral orbital varices. Carotid and vertebral angio­ Subtotal 17 grams in four patients did not contribute additional diagnostic information. Angiography was performed in one patient with 2. Complete external third CNP with partial pupil involvement: known diabetes because pupil-sparing third CNP progressed Ischemic third CNP 2 to complete pupillary dysfunction ipSilateral to the retroorbital headache on follow-up ophthalmologic examination . Ischemic 3. Partial external third CNP with partial pupil involvement: third CNP secondary to diabetes (either alone or in conjunc­ Meningeal carcinomatosis tion with hypertension)
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