Third nerve palsy: analysis of 1400 personally-examined inpatients.

BACKGROUND: Most studies of third nerve palsy (TNP) antedate computerized imaging and focus primarily on chart review of referral outpatients. METHODS: To compare a large contrasting population, I reviewed 1400 personally-examined municipal hospital inpatients with TNPs seen over 37 years. RESULTS: TNPs were bilateral in 11%, complete in 33%, without other neurological signs (isolated) in 36%, and associated with recurrent cranial neuropathies in 7%. Third nerve damage occurred in the subarachnoid space in 32%, the cavernous sinus in 23%, the brainstem in 14%, as a nonlocalized peripheral neuropathy in 18% and at an uncertain location in 13%. Causes were trauma (26%), tumor (12%), diabetes (11%), aneurysm (10%), surgery (10%), stroke (8%), infection (5%), Guillain-Barre and Fisher syndromes (5%), idiopathic cavernous sinusitis (3%), benign self-limited (2%), miscellaneous (4%), and unknown (3%). Local causes, besides an abundance of trauma, included six cases involving cysticercosis, four with wound botulism, and one with coccidiomycotic meningitis. Of 234 patients with diabetes, microvascular ischemia was the cause of TNP in only two-thirds (five had aneurysms) and 53% of those with diabetic microvascular ischemia had pupillary involvement-often bilateral, suggesting concomitant autonomic neuropathy. Only 2% of aneurysms spared the pupil. Apainful onset occurred with 94% of aneurysm and 69% of diabetic cases. CONCLUSIONS: Bilateral TNPs, multiple cranial neuropathies, and accompanying neurological signs were common among our inpatients, as were causes rare in outpatient settings such as severe trauma, transtentorial herniation, midbrain strokes, and the Guillain-Barre syndrome. Few cases remained undiagnosed and nondiabetic ischemia was rare.

Bilateral ocular paralysis: analysis of 31 inpatients.

To my knowledge, no general study of complete ophthalmoplegia is available. This study was performed to determine the seats and causes of bilateral ocular paralysis. The personal records of 13 440 neurology and neurosurgery inpatients were reviewed. Eighteen (58%) of 31 patients had Fisher syndrome (13 cases) or Guillain-Barré syndrome (5 cases). Four cases resulted from midbrain infarction, 3 from myasthenia, and 1 each from pituitary apoplexy, skull base metastasis, botulism, mucormycosis, phenytoin toxicity, and trauma. Many conditions produce complete ophthalmoplegia on rare occasions, but Fisher syndrome, which paralyzes the eyes in nearly one third of cases, was by far the commonest cause.

Triplopia: thirteen patients from a neurology inpatient service.

BACKGROUND: Seeing triple is a rare complaint, so anatomically unlikely that it is often considered a diagnostic symptom of hysteria. OBJECTIVE: To evaluate the complaint of triple vision among a large group of neurological inpatients. DESIGN: Personal case series during a 34-year period. SETTING: Neurology and neurosurgery wards of the University of Southern California-Los Angeles County Medical Center. Patients Thirteen patients who reported seeing objects in triplicate. RESULTS: Eleven of 13 patients had ocular motor findings, including third nerve palsy in 5 patients, internuclear ophthalmoplegia in 4, and sixth nerve palsy in 2. Causes included brainstem infarction in 4 patients; ischemic mononeuropathy, trauma, surgery, and hysteria in 2 patients each; and tumor in 1 patient. CONCLUSION: Triplopia is a rare complaint that, in a neurology inpatient service, often represents an unusual interpretation of abnormal eye movements.

Multiple cranial nerve palsies: analysis of 979 cases.

BACKGROUND: To my knowledge, no large series of multiple cranial neuropathies is available. OBJECTIVES: To examine the seats and causes of multiple cranial neuropathies in a large group of inpatients. DESIGN: Personal case series. SETTING: Wards of a large municipal hospital and affiliated rehabilitation hospital. PATIENTS: A consecutive series of 979 unselected inpatients with simultaneous or serial involvement of 2 or more different cranial nerves. RESULTS: Cranial nerves VI (565 cases), VII (466 cases), V (353 cases), and III (339 cases) were most commonly affected. The locations and causes were diverse, with cavernous sinus (252 cases), brainstem (217 cases), and individual nerves (182 cases) being the most frequent sites, and tumor (305 cases), vascular disease (128 cases), trauma (128 cases), infection (102 cases), and the Guillain-Barré and Fisher syndromes (91 cases total) being the most frequent causes. Recurrent cranial neuropathy was uncommon (43 cases, 106 episodes, 136 nerves), with diabetes mellitus (14 cases), self-limited unknown causes (14 cases), and idiopathic cavernous sinusitis (10 cases) being the usual causes. CONCLUSION: While the locations and causes of multiple cranial neuropathy are highly diverse, the fact that tumor composes more than one quarter of cases places a premium on prompt diagnosis.

Bilateral involvement of a single cranial nerve: analysis of 578 cases.

The author reviewed 34 years of personal experience with inpatients in a large municipal hospital to analyze the seats and causes of involvement of single pairs of cranial nerves. Among 578 cases, the sixth (n = 234) and second (211) nerves predominated, followed by the fourth (48), seventh (30), third (27), and eighth (18) cranial nerves. Trauma (99), infection (94), tumor (92), increased intracranial pressure (85), vascular disease (74), and demyelination (66) were common causes.

Internuclear ophthalmoplegia: unusual causes in 114 of 410 patients.

Internuclear ophthalmoplegia (INO) is a sign of exquisite localizing value, often due to either multiple sclerosis or infarction. To demonstrate that unusual causes of INO are more common than the 11% reported in previous series, this review considers a case series of 410 inpatients whom I personally examined during a 33-year period. In this series, the cause of INO was infarction in 157 patients (38%), multiple sclerosis in 139 (34%), and unusual causes in 114 (28%). Unusual causes included trauma (20 cases), tentorial herniation (20 cases), infection (17 cases), tumor (17 cases), iatrogenic injury (12 cases), hemorrhage (13 cases), vasculitis (7 cases), and miscellaneous (8 cases). Internuclear ophthalmoplegia was unilateral in 136 of the infarct cases (87%), 38 of those with multiple sclerosis (27%), and 48 of the unusual cases (42%). Because unusual causes compose more than one quarter of the cases, the differential diagnosis of INO should be tripartite: multiple sclerosis, stroke, and other causes.