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Oculomotor Nerve Palsy: Differential Diagnoses & Workup

Author: James Goodwin, MD, Director of Neuro-Ophthalmology, Associate Professor, Departments of Neurology and Ophthalmology, University of Illinois College of Medicine
Contributor Information and Disclosures

Updated: Dec 3, 2008

Differential Diagnoses

Anisocoria
Meningioma, Sphenoid Wing
Chronic Progressive External Ophthalmoplegia
Mucormycosis
Contact Lens Complications
Multiple Sclerosis
Diplopia
Myasthenia Gravis
Exotropia, Acquired
Neuro-ophthalmic History
Exotropia, Congenital
Orbital Fracture, Apex
Extraocular Muscles, Actions
Pituitary Apoplexy
Extraocular Muscles, Anatomy
Ptosis, Adult
Fistula, Carotid Cavernous
Ptosis, Congenital
Giant Cell Arteritis
Sarcoidosis
Headache, Children
Thyroid Ophthalmopathy
Headache, Migraine
Trochlear Nerve Palsy

Workup

Imaging Studies

  • MRI/MRA
    • MRI is a more sensitive imaging technique than CT scan for picking out a small intraparenchymal brainstem lesion, such as infarction, small abscess, or tumor.
    • MRI is also the procedure of choice for demonstrating meningeal and dural inflammation and infiltration.
    • Abnormal signal intensity and enhancement in the intracavernous portion of the third cranial nerve has been demonstrated in a case of herpes zoster with third cranial nerve palsy.6
    • Diffusion tensor imaging with 3-mm slice thickness has even demonstrated a small infarct in the midbrain involving the intraparenchymal segment of the third cranial nerve in a patient with acute onset third cranial nerve palsy.7
    • MRI/MRA also gives more specific information than CT scan on vascular flow patterns and is better for picking up lesions in the cavernous sinus, including aneurysm.
    • MRA using 1.5-Tesla or lower strength magnet is probably not adequate to rule out berry aneurysm causing third cranial nerve palsy, although 3-Tesla MRA with special attention to the circle of Willis can be definitive in this regard on account of enhanced resolution.
  • CT scan
    • CT scan is more sensitive than MRI to demonstrate subarachnoid hemorrhage.
    • CT scan is also better than MRI for demonstrating calcification within lesions, as may be found in certain tumors and in large aneurysms.
    • Sixteen-row multislice CT angiography rivals digital subtraction catheter angiography in sensitivity and specificity for detecting intracranial aneurysms.8,9  

Procedures

  • Lumbar puncture
    • The main purpose of lumbar puncture is to demonstrate the presence of blood in cerebrospinal fluid, an inflammatory reaction, neoplastic infiltration, or infection.
    • Bloody spinal fluid with oculomotor nerve palsy usually results from rupture of a posterior communicating artery berry aneurysm.
    • Meningeal inflammatory reaction may be idiopathic or may result from a specific infection that should be diagnosed by bacterial and fungal cultures and by fungus, protozoan, or virus-specific serology or specific antigen (polymerase chain reaction).
  • Cerebral angiography
    • Conventional angiography is the definitive test for berry aneurysm in all intracranial locations.
    • A small but definite risk of angiography causing serious complication, such as embolic stroke, exists. This risk varies with each institution and individual who does the procedure.
    • Angiography is indicated in a patient with third cranial nerve palsy and dilated, light-fixed pupil. It may be indicated in a patient younger than 55-60 years, especially without a history of long-standing diabetes, hypertension, or both.
    • When external ophthalmoplegia is partial, pupil sparing is not a reliable indicator of ischemia as opposed to aneurysm as the etiology, so angiography may be warranted in this setting, especially if the patient is young or lacks ischemic risk factors.

Histologic Findings

Cytologic examination of cerebrospinal fluid is used to diagnose meningeal carcinomatosis and lymphomatous or leukemic infiltration.

More on Oculomotor Nerve Palsy

Overview: Oculomotor Nerve Palsy
Differential Diagnoses & Workup: Oculomotor Nerve Palsy
Treatment & Medication: Oculomotor Nerve Palsy
Follow-up: Oculomotor Nerve Palsy
Multimedia: Oculomotor Nerve Palsy
References
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References

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Further Reading

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Keywords

oculomotor nerve palsy, third cranial nerve palsy, third cranial nerve

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Contributor Information and Disclosures

Author

James Goodwin, MD, Director of Neuro-Ophthalmology, Associate Professor, Departments of Neurology and Ophthalmology, University of Illinois College of Medicine
James Goodwin, MD is a member of the following medical societies: American Academy of Neurology, Illinois State Medical Society, North American Neuro-Ophthalmology Society, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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