Third Nerve Palsy; Aberrant Reinnervation

Ptosis; Third Nerve Palsy; Aberrant Reinnervation of the Third NervePowerPoint Presentation: Cavernous Sinus Meningioma: http://novel.utah.edu/Wray/PPT/Cavernous_Sinus_Meningioma.pdf Shirley H. Wray, M.D., Ph.D., FRCP, Harvard Medical SchoolPtosisThe patient is a 48 year old man from Saudi Arabia who came to the Massachusetts General Hospital for a second opinion and hopefully for surgical correction of ptosis of the left eye (OS). He had a long standing left third nerve palsy due to compression of the nerve trunk by a cavernous sinus meningioma. Neuro-Ophthalmological examination: Visual acuity 20/25 OU Visual fields, and fundus examination normal. Eyelid OS: Prominent signs of aberrant reinnveration of the left third nerve present with changes in the position of the ptotic eyelid on abduction and adduction. Partial ptosis in primary gaze Complete ptosis on abduction Striking elevation of the ptotic lid on adduction. Ocular motility OS: Paresis of all the muscles innervated by the third nerve Superior oblique (cranial nerve 4) normal Lateral rectus (cranial nerve 6) normal Diagnosis: Compressive lesion of the left third nerve trunk within the cavernous sinus Primary aberrant reinnervation of the third nerve. Brain MRI: Showed a contrast enhancing mass expanding the left cavernous sinus.This patient with longstanding compression of the left third nerve from a cavernous sinus meningioma strikingly illustrates the signs of aberrant reinnervation of the third nerve. Eyelid OS: Prominent signs of aberrant reinnveration of the left third nerve present with changes in the position of the ptotic eyelid on abduction and adduction. Partial ptosis in primary gaze Complete ptosis on abduction Striking elevation of the ptotic lid on adduction. Ocular motility OS: Paresis of all the muscles innervated by the third nerve Superior oblique (cranialo nerve 4) normal Lateral rectus (cranial nerve 6) normal Eyelid signs of aberrant reinnervation of the third nerve are usually less prominent and only detected if the position of the eyelid is carefully checked during eye movement. Most commonly, the lid elevates during adduction (as in this case) or depression of the eye. Other common patterns include depression of the lid on abduction and pupillary constriction on adduction or depression of the eye. In this case the patient also had elevation of the eyelid on attempted upgaze. No constriction of the dilated pupil was noted. Primary aberrant reinnervation of the third nerve is a common sequel of long standing third nerve lesions which include compression from a slow growing intracavernous meningioma or carotid aneurysm. This unusual synkinesis is also reported following trauma, as a complication of neurosurgery, and with congenital third nerve palsy, Aberrant reinnervation almost never occurs with diabetic third nerve palsy. The abnormal eyelid movements are due to co-contraction of muscles innervated by the third nerve. The regenerating fibers no longer follow their previous paths but innervate different muscles supplied by the third nerve. This mechanism may not apply in every case since anomalous synkinesis can occur transiently after an acute third nerve palsy. It is noteworthy that primary aberrant reinnervation has also been reported following a mesencephalic lesion affecting the third nerve fascicles.View Cavernous Sinus Meningioma to see imaging studies.The diagnosis of a third nerve palsy is straight forward but it is important to consider whether it is: 1. A nuclear lesion 2. A complete or partial lesion of the nerve trunk or a 3. Superior division of the third nerve or an 4. 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