Case #6 Third Nerve Palsy

History

58- year-old woman with lifelong history of migraine develops a severe headache different from her usual migraines. 36 hours into the headache she develops an incomplete third nerve palsy with a dilated pupil.

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Question #1

What historical questions would you like answered?

Question #2

What tests would you order and in what sequence?

Question #3

Is this an emergency? Why or why not?

Question #4

What is the significance of the large pupil?

Question #5

Would you expect this person to develop aberrant regeneration of her third nerve?

Question #6

What are the classic pathophysiologic mechanisms of third nerve palsy?

Question #7

What anatomical location of the third nerve is involved in this case?

Question #8

What age range is ophthalmoplegic migraine ususally seen?

References

Green W, Hackett E, Schlezinger N: Neuro-ophthalmologic evaluation of oculomotor nerve paralysis. Arch Ophthalmol 1964; 72:154.

Rush JA, Younge BR: Paralysis of cranial nerves III, IV, V. Cause and prognosis in 1000 cases. Arch Ophthalmol. 1981; 99:76.

Schatz JA, Savino PJ, Corbett JJ: Primary aberrant oculomotor regeneration. A sign of cavernous meningioma. Arch Neurol. 1977; 34:29.

Corbett JJ: Neuro-ophthalmic complications of migraine and cluster headaches. Neurol Clin. 1983; 1: 973-995.

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