A review of isolated third nerve palsy without subarachnoid hemorrhage using computed tomographic angiography as the first line of investigation
ABSTRACT Digital subtraction angiography is recognized as the standard investigation for isolated third nerve palsy thought to be caused by an expanding aneurysm. We reviewed our experience in using computed tomographic angiography (CTA) as the first line investigation for patients presenting with isolated third nerve palsy without subarachnoid hemorrhage.
We retrieved the medical records of 34 patients who had presented with isolated third nerve palsy without associated subarachnoid hemorrhage to our institution between January 1998 and July 2001. The clinical history, course and outcome as well as the radiological data was reviewed.
A total of nine structural lesions (26%) were noted as the etiology of the third nerve palsy. All of the five posterior communicating artery aneurysms were picked up by the CTA. Neither the presence nor the absence of painful complete third nerve palsy was of diagnostic value for intracranial aneurysm.
A good quality CTA is sufficient to detect a compressive aneurysm and may detect other structural lesions. This allows neurosurgeons to plan the management of patients with isolated third nerve palsy. Patients in whom CTA results are inconclusive should be further investigated with catheter angiography.
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ABSTRACT: Significant developments have occurred in the imaging of acute stroke. First and foremost, one must distinguish primary ischemic from primary hemorrhagic stroke. This is the first tier of the mechanistic approach. For primary ischemic stroke, one must try to sort out embolic from thrombotic or thromboembolic. Various potential mechanisms have to be addressed in terms of mechanism, including hemodynamic-mediated watershed-type infarcts, sinovenous occlusive disease, vasculopathies such as primary central nervous system vasculitis, connective tissue disorders, infectious processes such as syphilis and idiopathic occlusive processes such as moyamoya disease, and vascular dissection. Primary hemorrhagic stroke can include the most common, hypertensive intracerebral hemorrhage, as well as intracerebral bleeding secondary to aneurysms or arteriovenous malformations. There has been a tremendous refinement in the approach toward both primary ischemic and primary hemorrhagic stroke, because newer imaging techniques can provide an in vivo glimpse of metabolic and blood flow status and allow determination of potential salvageable brain tissue. Several noninvasive vascular imaging techniques allow ready evaluation of the integrity of the cerebral vasculature in patients with stroke. Such information can be important in assessing response to interventional therapy and providing prognostic information in terms of functional outcome. However, one must sort through the true value of such newer techniques to prevent unacceptable costs for imaging that do not have an impact on patient management.International Review of Neurobiology 02/2005; 67:203-38. DOI:10.1016/S0074-7742(05)67007-9 · 1.92 Impact Factor
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ABSTRACT: We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.Revue Neurologique 05/2005; 161(5):531-542. DOI:10.1016/S0035-3787(05)85087-8 · 0.66 Impact Factor
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