Case 22: unusual cause for an acute third nerve palsy

posted: September 3, 1997

Resident: Bryan Payne, MD
Attending: Touissiant LeClercq, MD

CLINICAL PRESENTATION: This 45 year old black man presented with a 2 day history of double vision. Patient had an associated frontal headache, but no nausea or vomiting. There was no photophobia or stiff neck. The patient complained only of double vision and denied decreased vision. Patient denied any history of diabetes mellitus. In addition there were no other endocrine abnormalities elicited upon questioning. Patient denied any history of hypertension, heart disease, peripheral vascular disease.

EXAMINATION: On examination, the patient was awake and alert and in no distress (he was complaining of a moderate headache). Blood pressure: 140/70; pulse: 78; resp: 20; afebrile. The patient was completed oriented. He did not have a stiff neck. The neurological exam revealed a right third nerve paresis (dilated and sluggishly reactive pupil; weakness of the medial, inferior and superior recti muscles). No other focal neurological abnormalities were noted. The general physical examination was normal.

What is your differential diagnosis and what diagnostic studies would you order?

Please comment: dawast@lsuhsc.edu

DIAGNOSTIC STUDIES: The initial study was a cranial CT scan which revealed no subarachnoid hemorrhage; there was a hint of a suprasellar mass. The next study was a cerebral angiogram which revealed no aneurysm or AVM. The angiogram did show both A1s to be elevated (indicating mass effect from a suprasellar lesion). The next study was a MRI scan with and without contrast as well as special sequences to visualize blood products:

T1-weighted images with contrast. Axial study on the left shows a ring-enhancing mass in the sellar region (red marker). The coronal views on the right confirm the sellar/ suprasellar mass.

Special sequence to highlight blood products reveals blood in the sellar mass (red marker). Download a larger image of above. Thus, the patient suffered pituitary apoplexy.

STEPS TAKEN AT LSU: Patient was taken to the OR and through a trans-sphenoidal appraoch, the pituitary tumor (null cell adenoma) was resected. Intraoperative there was partial necrosis and old hemorrhage in the tumor.

Postoperatively, the patient made a partial recovery of his third nerve function. He did not have diabetes insipidus. He was placed on steroid replacement.

Comments and Questions about this interesting case are welcomed. Please e-mail: dawast@lsuhsc.edu

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