Cause of acquired onset of diplopia due to isolated third, fourth, and sixth cranial nerve palsies in patients aged 20 to 50 years in Korea: A high resolution magnetic resonance imaging study

Published:October 19, 2019DOI:https://doi.org/10.1016/j.jns.2019.116546

      Highlights

      • Inflammation was the most common cause of 3rd nerve palsy in patients aged 20–50 years.
      • Neoplasm was the most common cause of 6th nerve palsy in patients aged 20–50 years.
      • Ischemia was the most common cause of 4th nerve palsy in patients aged 20–50 years.
      • Other causes of ocular motor nerve palsy included aneurysm, stroke, and hemorrhage.

      Abstract

      Aims

      This study aimed to describe the etiologies of acquired onset of diplopia due to isolated third, fourth, and sixth cranial nerve palsies in young adults in Korea.

      Methods

      This retrospective study included 127 patients aged 20 to 50 years with acquired onset isolated third, fourth, and sixth cranial nerve palsies who received care at the Strabismus and Neuro-ophthalmology Department of Samsung Medical Center from 2013 to 2017. The etiologies of the palsies determined by clinical assessment, high-resolution magnetic resonance imaging (MRI) with three-dimensional constructive interference in steady state, and laboratory testing were analyzed.

      Results

      Fifty-nine patients manifested sixth cranial nerve palsy. Forty-six patients had fourth cranial nerve palsy and 22 patients had third cranial nerve palsy. The most common etiologies of the ocular motor nerve palsies were presumed inflammatory lesions (21.3%), followed by presumed microvascular causes (17.3%), and neoplasms involving the central nervous system (15.7%). Neoplasms were the most common cause of sixth cranial nerve palsy (25.4%). The most common cause of fourth cranial nerve palsy was presumed microvascular ischemia (28.3%), and presumed inflammatory lesions was the most common cause of third cranial nerve palsy (36.4%). Other non-traumatic causes included vascular lesions, ischemic brainstem stroke, intracranial hemorrhage, non-aneurysmal neuro-vascular contact, multiple sclerosis, and infection.

      Conclusion

      A substantial proportion of young adult patients with ocular motor nerve palsies manifested pathologies other than presumed microvascular ischemia or idiopathic causes. Neuroimaging and laboratory tests have important roles in the evaluation of patients aged 20–50 years with acquired ocular motor nerve palsies.

      Keywords

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      References

        • Moster M.L.
        • Savino P.J.
        • Sergott R.C.
        • Bosley T.M.
        • Schatz N.J.
        Isolated sixth-nerve palsies in younger adults.
        Arch. Ophthalmol. 1984; 102: 1328-1330
        • Peters 3rd, G.B.
        • Bakri S.J.
        • Krohel G.B.
        Cause and prognosis of nontraumatic sixth nerve palsies in young adults.
        Ophthalmology. 2002; 109: 1925-1928
        • Park K.A.
        • Oh S.Y.
        • Min J.H.
        • Kim B.J.
        • Kim Y.
        Acquired onset of third, fourth, and sixth cranial nerve palsies in children and adolescents.
        Eye (Lond.). 2019; 33: 965-973
        • Park K.A.
        • Min J.H.
        • Oh S.Y.
        • Kim B.J.
        Idiopathic third and sixth cranial nerve neuritis.
        Jpn. J. Ophthalmol. 2019; 63: 337-343
        • Jacobson D.M.
        • McCanna T.D.
        • Layde P.M.
        Risk factors for ischemic ocular motor nerve palsies.
        Arch. Ophthalmol. (Chicago, Ill.: 1960). 1994; 112: 961-966
        • Classification Committee of the International Headache Society
        The international classification of headache disorders, 3rd edition (beta version).
        Cephalalgia. 2013; 33: 629-808
        • Cohen A.R.
        • Cooper P.R.
        • Kupersmith M.J.
        • Flamm E.S.
        • Ransohoff J.
        Visual recovery after transsphenoidal removal of pituitary adenomas.
        Neurosurgery. 1985; 17: 446-452
        • Poon A.
        • McNeill P.
        • Harper A.
        • O’Day J.
        Patterns of visual loss associated with pituitary macroadenomas.
        Aust. N. Z. J. Ophthalmol. 1995; 23: 107-115
        • Sullivan L.J.
        • O’Day J.
        • McNeill P.
        Visual outcomes of pituitary adenoma surgery. St. Vincent’s hospital 1968-1987.
        J. Clin. Neuro-Ophthalmol. 1991; 11: 262-267
        • Kline L.B.
        • Hoyt W.F.
        The Tolosa-Hunt syndrome.
        J. Neurol. Neurosurg. Psychiatry. 2001; 71: 577-582
        • Nelson D.A.
        • Holloway W.J.
        • Kara-Eneff S.C.
        • Goldenberg H.I.
        Neurological syndromes produced by sphenoid sinus abscess.
        Neurology. 1967; 17: 981-987
        • Fanous M.M.
        • Margo C.E.
        • Hamed L.M.
        Chronic idiopathic inflammation of the retropharyngeal space presenting with sequential abducens palsies.
        J. Clin. Neuroophthalmol. 1992; 12: 154-157
        • Tay E.
        • Gibson A.
        • Chaudhary N.
        • Olver J.
        Idiopathic orbital inflammation with extensive intra- and extracranial extension presenting as 6th nerve palsy—a case report and literature review.
        Orbit. 2008; 27: 458-461
        • Adesina O.O.
        • Scott J.
        • McNally K.L.
        • Salzman B.J.
        • Katz J.E.A.
        • Warner M.M.
        • et al.
        Diffusion-weighted imaging and post-contrast enhancement in differentiating optic neuritis and non-arteritic anterior optic neuropathy.
        Neuro-Ophthalmol. (Aeolus Press). 2018; 42: 90-98
        • Miller R.W.
        • Lee A.G.
        • Schiffman J.S.
        • Prager T.C.
        • Garza R.
        • Jenkins P.F.
        • et al.
        A practice pathway for the initial diagnostic evaluation of isolated sixth cranial nerve palsies.
        Med. Decis. Mak. 1999; 19: 42-48
        • Akagi T.
        • Miyamoto K.
        • Kashii S.
        • Yoshimura N.
        Cause and prognosis of neurologically isolated third, fourth, or sixth cranial nerve dysfunction in cases of oculomotor palsy.
        Jpn. J. Ophthalmol. 2008; 52: 32-35
        • Park U.C.
        • Kim S.J.
        • Hwang J.M.
        • Yu Y.S.
        Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy.
        Eye (London, England). 2008; 22: 691-696
        • Sanders S.K.
        • Kawasaki A.
        • Purvin V.A.
        Long-term prognosis in patients with vasculopathic sixth nerve palsy.
        Am J. Ophthalmol. 2002; 134: 81-84
        • Patel S.V.
        • Mutyala S.
        • Leske D.A.
        • Hodge D.O.
        • Holmes J.M.
        Incidence, associations, and evaluation of sixth nerve palsy using a population-based method.
        Ophthalmology. 2004; 111: 369-375
        • Asbury A.K.
        • Aldredge H.
        • Hershberg R.
        • Fisher C.M.
        Oculomotor palsy in diabetes mellitus: a clinico-pathological study.
        Brain. 1970; 93: 555-566
        • Dreyfus P.M.
        • Hakim S.
        • Adams R.D.
        Diabetic ophthalmoplegia; report of case, with postmortem study and comments on vascular supply of human oculomotor nerve.
        AMA Arch. Neurol. Psychiatry. 1957; 77: 337-349
        • Weber R.B.
        • Daroff R.B.
        • Mackey E.A.
        Pathology of oculomotor nerve palsy in diabetics.
        Neurology. 1970; 20: 835-838
        • Tiffin P.A.
        • MacEwen C.J.
        • Craig E.A.
        • Clayton G.
        Acquired palsy of the oculomotor, trochlear and abducens nerves.
        Eye (Lond.). 1996; 10: 377-384
        • Rucker C.W.
        Paralysis of the third, fourth and sixth cranial nerves.
        Am J. Ophthalmol. 1958; 46: 787-794
        • Alter M.
        • Good J.
        • Okihiro M.
        Optic neuritis in Orientals and Caucasians.
        Neurology. 1973; 23: 631-639
        • Lee S.
        • Kim S.H.
        • Yang H.K.
        • Hwang J.M.
        • Kim J.H.
        • Kim J.S.
        • et al.
        Imaging demonstration of trochlear nerve agenesis in superior oblique palsy emerging during the later life.
        Clin. Neurol. Neurosurg. 2015; 139: 269-271
        • Boecher-Schwarz H.G.
        • Bruehl K.
        • Kessel G.
        • Guenthner M.
        • Perneczky A.
        • Stoeter P.
        Sensitivity and specificity of MRA in the diagnosis of neurovascular compression in patients with trigeminal neuralgia. A correlation of MRA and surgical findings.
        Neuroradiology. 1998; 40: 88-95
        • Du C.
        • Korogi Y.
        • Nagahiro S.
        • Sakamoto Y.
        • Takada A.
        • Ushio Y.
        • et al.
        Hemifacial spasm: three-dimensional MR images in the evaluation of neurovascular compression.
        Radiology. 1995; 197: 227-231
        • Joshi S.
        • Tee W.W.H.
        • Franconi C.
        • Prentice D.
        Transient oculomotor nerve palsy due to non-aneurysmal neurovascular compression.
        J. Clin. Neurosci. 2017; 45: 136-137
        • Tsai T.H.
        • Demer J.L.
        Nonaneurysmal cranial nerve compression as cause of neuropathic strabismus: evidence from high-resolution magnetic resonance imaging.
        Am. J. Ophthalmol. 2011; 152 (e1062): 1067-1073
        • Hashimoto M.
        • Ohtsuka K.
        • Akiba H.
        • Harada K.
        Vascular compression of the oculomotor nerve disclosed by thin-slice magnetic resonance imaging.
        Am J. Ophthalmol. 1998; 125: 881-882
        • Liang C.
        • Du Y.
        • Lin X.
        • Wu L.
        • Wu D.
        • Wang X.
        Anatomical features of the cisternal segment of the oculomotor nerve: neurovascular relationships and abnormal compression on magnetic resonance imaging.
        J. Neurosurg. 2009; 111: 1193-1200
        • Nakagawa H.
        • Nakajima S.
        • Nakajima Y.
        • Furuta Y.
        • Nishi O.
        • Nishi K.
        Bilateral oculomotor nerve palsies due to posterior cerebral arterial compression relieved by microvascular decompression—case report.
        Neurol. Med. Chir. 1991; 31: 45-48