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“Please examine this patient’s cranial nerves.”
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This patient has a IIIrd cranial nerve palsy.
A patient with 3th nerve (also called oculomotor nerve) palsy will present with the complaint of diplopia. Subsequently, symptoms like ptosis, loss of light reflex and blurring of vision due to loss of accommodation may also develop. The oculomotor nerve serves the superior rectus, inferior rectus, inferior oblique, medial rectu and levator palpebrae superioris muscles (all somatic) as well as the autonomic pupillary sphincter and ciliary muscles of the eye.
Diplopia caused by typical 3rd cranial nerve palsy is binocular, mixed, horizontal and vertical due to the deviation of two visual axes. Damage to fascicular portion of 3rd nerve at any level of its track is most common. Decreased function of the muscles supplied by the nerve is usually combined whereas isolated muscular dysfunction is rarely seen. Ptosis, another common finding, may be evolved enough to cover the pupil resulting in inability to see. This may shadow the symptom of diplopia if ptosis precedes diplopia. Although not as significant symptomatically, the pupillary enlargement and loss of light reaction may cause glare and photoaversion in bright light. Other associated symptoms are very importance and patients should always be assessed for any associated headache, peri-ocular or orbital pain, red protruding eye, facial or body numbness and tremors, loss of smell or taste, involvement of other anatomically relevant cranial nerves (4th and 6th nerves), hearing loss, tinnitus or any other significant ophthalmic or neurological involvement.
Acquired causes of 3rd nerve palsy are vastly more common than congentical, which tend to be intra-uterine in origin from trauma or mid-development.
MRI/MRA (magnetic resonance imaging +/- angiography) is the superior modality over CT scan when suspecting intraparenchymal brainstem lesion including infection and vascular causes.
CT scan is more sensitive and hence prefered over MRI when suspecting:
● subarachnoid hemorrhage
● calcification within lesions
CT angiography surpasses digital subtraction catheter angiography in diagnosing an intracranial aneurysm.
Following are the portions of 3rd nerve that may be diseased with infarction, hemorrhage, neoplasm or abscess resulting in 3rd nerve palsy:
● nuclear portion
● fascicular midbrain portion
● fascicular subarachnoid portion
● fascicular cavernous sinus portion
● fascicular orbital portion
Older patients, those above than 60 years, and patients who are at risk of, or have atherosclerosis, diabetes and hypertension are at an increased risk. If there is no history of the afore mentioned conditions, then these should be thoroughly investigated for.
Palsy, the cardinal features of which include paralysis of the extraocular muscles and pain in the ipsilateral eye but sparing of pupillary sphincter is commonly seen. The aim of management is symptomatic relief of pain and diplopia as the condition tends to undergo spontaneous remission at 6-8 weeks after presentation. NSAIDs are the drug of choice for pain.
Diplopia can be managed by patching one eye for large angle deviation and horizontal and/or vertical Fresnel paste on prism for smaller angle deviation. Surgical management is more reliable and includes clipping, gluing, coiling or wrapping the berry aneurysm which causes symptoms through compression of the nerve.
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