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BRIEF COMMUNICATIONS: Daniel M. Jacobson Relative pupil-sparing third nerve palsy: Etiology and clinical variables predictive of a mass Neurology 2001; 56: 797-798 [Abstract] [Full text] [PDF]

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Reply to Ken Ikeda

Daniel M Jacobson   (26 June 2001)

Relative pupil-sparing third nerve palsy: Etiology and clinical variables predictive of a mass

K Ikeda, "Y Iwasaki, M Tamura, M Kinoshita"   (26 June 2001)

Reply to Ken Ikeda 26 June 2001
Daniel M Jacobson Marshfield Clinic Marshfield, WI Send Correspondence to journal: Re: Reply to Ken Ikeda jacobsod{at}mfldclin.edu Daniel M Jacobson	I thank Ikeda et al. for their interest in my paper. For clarification, I indicated in the Results section that “all but five patients were evaluated within 3 weeks from first symptoms.” This result referred to the entire study population, not just those with mass lesions.
Relative pupil-sparing third nerve palsy: Etiology and clinical variables predictive of a mass 26 June 2001
K Ikeda Tokyo Health Care Center Tokyo, Japan, "Y Iwasaki, M Tamura, M Kinoshita" Send Correspondence to journal: Re: Relative pupil-sparing third nerve palsy: Etiology and clinical variables predictive of a mass keni{at}pl-tokyo-kenkan.gr.jp K Ikeda, et al.	To the Editor: We read with great interest the article by Jacobson [1] concerning relative pupil-sparing third nerve palsy. He reports that compressive mass lesions were a common cause of relative pupil-sparing third nerve palsy. We performed brain MRI and MRA in 3366 patients between April 2000 and March 2001. Among those patients, we also encountered one unique patient who had pupil-sparing third nerve palsy due to an intracavernous carotid artery aneurysm. We would like to show such a patient and discuss the mechanism of pupillary sparing by mass lesions compressing the oculomotor nerve. A 95-year-old woman with hypertension and diabetes mellitus was diagnosed as diabetic external ophthalmoplegia in the right eye before 5 years. Her oculomotor symptoms progressed gradually. Recently, she developed headache and complete ptosis in the right eyelid. Neuro- ophthalmological examination revealed severe degree of third nerve palsy without pupil involvement in the right eye. Her pupils were 2.0 mm in equal size. Light reactions were normal in both eyes. Other neurologic examination remains normal. Brain MRI and MRA disclosed a giant aneurysm (2.8 cm in diameter) in the right anterior cavernous sinus. Jacobson [1] suggests that compressive mass lesions cause relative pupil-sparing third nerve palsy, in addition to third nerve infarction. Our patient had a giant aneurysm in the anterior cavernous sinus. Duration of external ophthalmoplegia in our patient was 5 years. We speculate the possibility that slow expanding mass lesions compressing the oculomotor nerve contribute to pupil-sparing third nerve palsy. Several of Jacobson's patients [1] also contained slow enlarging mass lesions, such as intracavernous carotid artery aneurysms and parasellar meningioma. Their nineteen patients are evaluated within 3 weeks from the initial symptom. We would like to know the duration of third nerve palsy in his 10 patients with mass lesions. Another report shows that a 69-year-old woman had isolated oculomotor superior division palsy due to a large aneurysm in the anterior portion of cavernous sinus. [2] In compressive third nerve palsy, the topographic relationship and degree of compression between the parasympathetic pupilloconstricutor fibers of oculomotor nerve and mass lesions might play a crucial rule in the mechanism of pupillary sparing. Otherwise, ischemic damage could induce pupil-sparing third nerve palsy in patients with third nerve infarction or diabetes mellitus. The second question is the age of his patients with mass lesions. Our patient was 95-years-old. The possibility is suspected that pupil- sparing third nerve palsy by compression may occur in older patients, in comparison with younger patients. Our patient had a history of hypertension and diabetes. In senile patients with persistent pupil- sparing third nerve palsy, we should cautiously evaluate mass lesions compressing the oculomotor nerve using MRI and MRA although those patients have vascular risk factors. References 1. Jacobson DM. Relative pupil-sparing third nerve palsy: Etiology and clinical variables predictive of a mass. Neurology 2001;56:797-798. 2.Silva MN, Saeki N, Hirai S, Yamaura A. Unusual cranial nerve palsy caused by cavernous sinus aneurysms: Clinical and anatomical considerations reviewed. Surg Neurol 1999;52:143-149.