Isolated Third Cranial Nerve Palsy in Pituitary Apoplexy: Case Report and Systematic Review

Abstract

Objectives: To report a case of isolated third nerve palsy from pituitary apoplexy and perform a systematic literature review.

Materials and methods: MEDLINE/EMBASE databases were searched up to September 2020.

Inclusion criteria: Age≥18, isolated third nerve palsy from pituitary apoplexy.

Exclusion criteria: Age<18, presence of other neurological findings, no hemorrhage or infarction of pituitary.

Results: Case report: A 76-year-old woman presented with headache and right-sided ptosis. Right-eye exam revealed complete ptosis, absent pupillary constriction and accommodation, depressed and abducted eye on primary gaze, and -1 impaired depression, adduction, elevation, without other neurological findings. Brain MRI was suggestive of pituitary apoplexy. Pathology after transsphenoidal resection revealed an infarcted pituitary adenoma. Third nerve palsy resolved completely in 21 days. Systematic review: Twenty-three studies reporting 35 patients were selected from 182 abstracts. Twenty-nine (83%) had complete isolated third nerve palsy. Headache was reported in 31 (97%). Thirty-one had hemorrhage and 1 had infarction of pituitary. Cavernous sinus invasion occurred in 14 (50%). Twenty-eight were managed surgically (80%) and 7 medically (20%). Nerve palsy resolved completely in 27 (82%) and partially in 4 (11%).

Conclusions: Pituitary apoplexy is an important differential diagnosis in patients with isolated third nerve palsy. Isolated third nerve palsy in apoplexy appears to have favorable prognosis.

Keywords: Oculomotor palsy; Pituitary adenoma; Pituitary apoplexy; Third nerve palsy; Transsphenoidal resection.