Oculomotor Nerve Palsy Workup
- Author: James Goodwin, MD; Chief Editor: Andrew G Lee, MD more...
Angiographic imaging studies (eg, computed tomographic angiography [CTA], magnetic resonance angiography [MRA], digital subtraction angiography [DSA]) are often necessary in the evaluation of acute oculomotor nerve palsy.
The combination of CT scanning/CTA followed by MRI/MRA is often necessary in the evaluation of unexplained oculomotor nerve palsy. Standard catheter angiography may be required upon high clinical suspicion for aneurysm.
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.
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.
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 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.[10, 11]
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).
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. See the image below.
Cytologic examination of cerebrospinal fluid is used to diagnose meningeal carcinomatosis and lymphomatous or leukemic infiltration.
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