Third Nerve Palsy; Aberrant Reinnervation

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Identifier 167-8
Title Third Nerve Palsy; Aberrant Reinnervation
Ocular Movements Ptosis; Third Nerve Palsy; Aberrant Reinnervation of the Third Nerve
Creator Shirley H. Wray, M.D., Ph.D., FRCP, Professor of Neurology Harvard Medical School, Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Contributor Primary Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Subject Ptosis; Unilateral Third Nerve Palsy; Aberrant Reinnervation of the Third Nerve; Pupil Dilated and Fixed; Oculomotor Nerve; Cavernous Sinus Meningioma; Cavernous Sinus Syndrome; Aberrant Reinnervation
Supplementary Materials PowerPoint Presentation: Cavernous Sinus Meningioma: http://novel.utah.edu/Wray/PPT/Cavernous_Sinus_Meningioma.pdf Shirley H. Wray, M.D., Ph.D., FRCP, Harvard Medical School
Presenting Symptom Ptosis
History The patient is a 48 year old man from Saudi Arabia who came to the Massachusetts General Hospital for a second opinion and hopefully for surgical correction of ptosis of the left eye (OS). He had a long standing left third nerve palsy due to compression of the nerve trunk by a cavernous sinus meningioma. Neuro-Ophthalmological examination: Visual acuity 20/25 OU Visual fields, and fundus examination normal. Eyelid OS: Prominent signs of aberrant reinnveration of the left third nerve present with changes in the position of the ptotic eyelid on abduction and adduction. Partial ptosis in primary gaze Complete ptosis on abduction Striking elevation of the ptotic lid on adduction. Ocular motility OS: Paresis of all the muscles innervated by the third nerve Superior oblique (cranial nerve 4) normal Lateral rectus (cranial nerve 6) normal Diagnosis: Compressive lesion of the left third nerve trunk within the cavernous sinus Primary aberrant reinnervation of the third nerve. Brain MRI: Showed a contrast enhancing mass expanding the left cavernous sinus.
Clinical This patient with longstanding compression of the left third nerve from a cavernous sinus meningioma strikingly illustrates the signs of aberrant reinnervation of the third nerve. Eyelid OS: Prominent signs of aberrant reinnveration of the left third nerve present with changes in the position of the ptotic eyelid on abduction and adduction. Partial ptosis in primary gaze Complete ptosis on abduction Striking elevation of the ptotic lid on adduction. Ocular motility OS: Paresis of all the muscles innervated by the third nerve Superior oblique (cranialo nerve 4) normal Lateral rectus (cranial nerve 6) normal Eyelid signs of aberrant reinnervation of the third nerve are usually less prominent and only detected if the position of the eyelid is carefully checked during eye movement. Most commonly, the lid elevates during adduction (as in this case) or depression of the eye. Other common patterns include depression of the lid on abduction and pupillary constriction on adduction or depression of the eye. In this case the patient also had elevation of the eyelid on attempted upgaze. No constriction of the dilated pupil was noted. Primary aberrant reinnervation of the third nerve is a common sequel of long standing third nerve lesions which include compression from a slow growing intracavernous meningioma or carotid aneurysm. This unusual synkinesis is also reported following trauma, as a complication of neurosurgery, and with congenital third nerve palsy, Aberrant reinnervation almost never occurs with diabetic third nerve palsy. The abnormal eyelid movements are due to co-contraction of muscles innervated by the third nerve. The regenerating fibers no longer follow their previous paths but innervate different muscles supplied by the third nerve. This mechanism may not apply in every case since anomalous synkinesis can occur transiently after an acute third nerve palsy. It is noteworthy that primary aberrant reinnervation has also been reported following a mesencephalic lesion affecting the third nerve fascicles.
Neuroimaging View Cavernous Sinus Meningioma to see imaging studies.
Anatomy The diagnosis of a third nerve palsy is straight forward but it is important to consider whether it is: 1. A nuclear lesion 2. A complete or partial lesion of the nerve trunk or a 3. Superior division of the third nerve or an 4. Inferior division of the third nerve A lesion involving the superior division of the third nerve results in paresis of the levator palpebrae muscle and the superior rectus so that the patient will have partial ptosis and paresis of elevation in the line of action of the superior rectus. A lesion involving the inferior division of the third nerve, involves all the extraocular muscles innervated by the third nerve, except the levator palpabrae and the superior rectus with or without pupil involvement.
Pathology Meningiomas have a variable histological appearance but are composed of epithelial-like cells that form whorl patterns.
Etiology Meningioma
Disease/Diagnosis Cavernous sinus meningioma; Primary aberrant reinnervation of the third nerve
Treatment Focal radiation therapy
References 1. Balkan R, Hoyt CS. Associated neurological abnormalities in congenital third nerve palsies. Am J Ophthalmol 1984;97:319. http://www.ncbi.nlm.nih.gov/pubmed/6199980 2. Boghen D, Chartrand JP, Laflamme P, Kirkham T, Hardy J, Aube M. Primary aberrant third nerve regeneration. Ann Neurol 1979;6(5);415-418. http://www.ncbi.nlm.nih.gov/pubmed/518037 3. Braunstein JB, Vick NA. Meningiomas: the decision not to operate. Neurology 1997;48:1459-1462. http://www.ncbi.nlm.nih.gov/pubmed/9153494 4. Cox TA, Wurster JB, Godfrey WA. Primary aberrant oculomotor regeneration due to intracranial aneurysm. Arch Neurol 1979;36(9):570-571. http://www.ncbi.nlm.nih.gov/pubmed/224847 5. Fernandez E, Pallini R, Gangitano C, Del Fa A, Sangiacomo, CO, Talamonti G, Draicchio F, Sbriccoli A. Oculomotor nerve regeneration in rats. Functional, histological and neuroanatomical studies. J Neurosurg 1987;67:428-437. http://www.ncbi.nlm.nih.gov/pubmed/3612275 6. Guy, JR, Engel HM, Lessner Am. Acquired contralateral oculomotor synkinesis. Arch Neurol 1989;46:1021-1023. http://www.ncbi.nlm.nih.gov/pubmed/2775007 7. Iwabuchi T, Suzuki M, Nakaoka T, Suzuki S. Oculomotor nerve anastomosis. Neurosurgery 1982;10:490-491. http://www.ncbi.nlm.nih.gov/pubmed/7099398 8. Jordan DR, Miller DG, Anderson RL. Acquired oculomotor-abducens synkinesis. Can J Ophthalmol 1990;25:148-151. http://www.ncbi.nlm.nih.gov/pubmed/2361197 9. Kim DK, Grieve J, Archer DJ, Utttley D. Meningiomas in the region of the cavernous sinus: a review of 21 patients. Br. J Neurosurg 1996;10:439-444. http://www.ncbi.nlm.nih.gov/pubmed/8922701 10. Knosp E, Perneczky A, Koos WT, Fries G, Matula C. Meningiomas of the space of the cavernous sinus. Neurosurgery 1996;38:434-442. http://www.ncbi.nlm.nih.gov/pubmed/8837793 11. Laguna JF, Smith MS. Aberrant regeneration in idiopathic oculomotor nerve palsy. J Neurosurg 1980;52:854-856. http://www.ncbi.nlm.nih.gov/pubmed/7381547 12. Leigh RJ, Zee DS. Diagnosis of Peripheral Ocular Motor Palsies and Strabismus. Ch 9:385-474. In: The Neurology of Eye Movements, Fourth Edition. Oxford University Press, NY 2006. 13. Lepore FE, Glaser JS. Misdirection revisted. A critical appraisal of acquired oculomotor nerve synkinesis. Arch Ophthalmol 1980;98:2206-2209. http://www.ncbi.nlm.nih.gov/pubmed/7447776 14. Messe SR, Shin RK, Liu GT, Galetta SL, Volpe NJ. Oculomotor synkinesis following a midbrain stroke. Neurology 2001;57:1106-1107. http://www.ncbi.nlm.nih.gov/pubmed/11571345 15. Schatz NJ, Savino PJ, Corbett JJ. Primary aberrant oculomotor regeneration. A sign of intracavernous meningioma. Arch Neurol 1977;34(1):29-32. http://www.ncbi.nlm.nih.gov/pubmed/831685 16. Sebag J, Sadun AA. Aberrant regeneration of the third nerve following orbital trauma. Arch Neurol 1983;40:762-764. http://www.ncbi.nlm.nih.gov/pubmed/6625995 17. Sibony PA, Lessell S. Transient oculomotor synkinesis in temporal arteritis. Arch Neurol 1984;41:87-88. http://www.ncbi.nlm.nih.gov/pubmed/6689897 18. Sibony PA, Lessell S, Gittinger JW Jr. Acquired oculomotor synkinesis. Surv Ophthalmol 1984;28(5):382-390. http://www.ncbi.nlm.nih.gov/pubmed/6372143 19. Slavin ML, Einberg KR. Abduction defect associated with aberrant regeneration of the oculomotor nerve after intracranial aneurysm. Am J Ophthalmol 1996;121(5):580-582. http://www.ncbi.nlm.nih.gov/pubmed/8610809 20. Varma R, Miller NR. Primary oculomotor synkinesis caused by an extracavernous intradural aneurysm. Am J Ophthalmol 1994;118:83-87. http://www.ncbi.nlm.nih.gov/pubmed/8023880
Relation is Part of 5-1, 932-6, 939-2, 940-3
Contributor Secondary Ray Balhorn, Video Compressionist
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 1992
Type Image/MovingImage
Format video/mp4
Source 3/4" Umatic master videotape
Rights Management Copyright 2002. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Language eng
ARK ark:/87278/s6157dnp
Setname ehsl_novel_shw
Date Created 2008-09-23
Date Modified 2017-02-22
ID 188646
Reference URL https://collections.lib.utah.edu/ark:/87278/s6157dnp
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