Royal Australasian College of Physicians Examinations/Resources/Clinical Exam/Short Cases/Example Cases/3rd Nerve Palsy

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The 3rd Nerve Palsy

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Stem: This patient presents with a headache. Please examine his eyes.

Key Features

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  • dilated pupil
  • abducted and depressed eye with reduced movement
  • ipsilateral ptosis

Look for

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  • IV nerve palsy (tilt head towards side of lesion)
  • V nerve palsy (corneal reflex, sensation V1 / V2)
  • VI nerve palsy (lateral rectus palsy)
  • Contralateral UMN signs in Limbs = Weber's D

Example presentation

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This patient has a left 3rd nerve palsy, evidenced by a dilated pupil, and an abducted and depressed globe, with paralysis of movement and ptosis. There are no other cranial nerve abnormalities. The cause may be a berry aneurysm, causing headache and compressing the nerve. I would also consider a diabetic 3rd nerve palsy, or hypertension – although these would spare the pupil; or also a stroke in the midbrain, which would usually be accompanied by contralateral pyramidal signs; or a lesion in the cavernous sinus.

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