Third Cranial Nerve Palsy From Midbrain Neurocysticercosis: Repeated Exacerbation on Tapering Corticosteroids

Neurocysticercosis presenting with oculomotor nerve palsy: Case report and literature review

Neurocysticercosis (NCC), a central nervous system infection caused by the cystic larvae of Taenia Solium, is endemic in many low-to-middle income countries. NCC is known to have a variety of presentations depending on the size and site of involvement including chronic headaches, seizures, hydrocephalus, and ischemic insults. NCC has also been rarely associated with cranial nerve palsies. We report the case of a 26-year-old Nepalese lady who presented with isolated left-sided oculomotor nerve palsy and was found to have midbrain NCC. She was treated with anthelminthic agents and corticosteroids which led to clinical improvement. NCC can present with a variety of focal neurological syndromes. To the best of our knowledge, this is the first case report of NCC presenting with third cranial nerve palsy in the state of Qatar and the middle east. We also review the literature for other cases of NCC which presented with isolated oculomotor nerve palsy.

Cysticercosis in ophthalmology

Cysticercosis is caused by Taenia solium, a cestode or tapeworm that preferentially affects the subcutaneous tissue, brain, muscle, and the eye. It is traditionally a disease of low socioeconomic regions, but large-scale population migration has made it a matter of global concern. Its ocular invasion is a potentially blinding disease. In the last two decades, there has been considerable discussion of cysticercosis; however, most comes from a limited number of case observations. Thus, to overcome this limitation, we summarize and analyse twenty years of medical literature (from 2000 to 2020) on cysticercosis in ophthalmology.

Infectious ophthalmoplegias

Though infections account for a significant proportion of patients with ocular motor palsies, there is surprising paucity of literature on infectious ophthalmoplegias. Almost all types of infectious agents (bacteria, viruses, fungi and parasites) can lead to ocular motor palsies. The causative infectious agent can be diagnosed in most cases using an orderly stepwise approach. In this review we discuss how to approach a patient with ophthalmoplegia with main focus on infectious etiologies.

The Eye Opener: Finding and Targeting the Midbrain Lesion

Lesions of the central nucleus of the third cranial nerve in midbrain leads to bilateral ptosis. We present a case of a 14 year old boy, who was found to have B/L non-correctable ptosis and medial rectus palsy. There was a ring enhancing lesion in the midbrain in contrast MRI which resolved with treatment. The case exemplifies that bilateral ptosis results from the central nucleus involvement of third nerve which has bilateral innervation.

Managing the patient with oculomotor nerve palsy

PURPOSE OF REVIEW

To provide clinically relevant information regarding the evaluation and current treatment options for oculomotor nerve palsies. We survey recent literature and provide some insights into these studies.

RECENT FINDINGS

Recent case reports highlight emerging new causes of oculomotor cranial nerve palsies, including sellar chordoma, odontogenic abscess, nonaneurysmal subarachnoid hemorrhage, polycythemia, sphenoiditis, neurobrucellosis, interpeduncular fossa lipoma, metastatic pancreatic cancer, leukemia, and lymphoma. Surgical studies have focused on modifications and innovations regarding strabismus surgery for this condition. New globe fixation procedures may include fixation to the medial orbital wall by precaruncular and retrocaruncular approaches, apically based orbital bone periosteal flap fixation and the suture/T-plate anchoring platform system.

SUMMARY

Management of oculomotor nerve palsy depends in part upon the underlying cause and anatomical location of the lesion. Careful clinical evaluation and appropriate imaging can identify a definitive cause in most cases. Surgical options depend on the number, extent, and severity of the muscles involved as well as the presence or absence of signs of aberrant regeneration. The clinician should also address issues that arise due to involvement of the pupil and accommodation. Strabismus surgery can be challenging but also rewarding with appropriate selection and staging of procedures.

Bilateral ptosis: an atypical presentation of neurocysticercosis

Isolated ptosis is a rare presentation of neurocysticercosis (NCC). Here we report the case of a 45-year-old woman who presented with acute onset bilateral symmetrical ptosis with no other neurological deficit. Her imaging revealed a single cystic ring-enhancing lesion with perilesional oedema in the midbrain suggestive of NCC. She responded well to prednisolone.

Cysticercosis of midbrain presenting with fluctuating ptosis

Fluctuating ptosis is usually caused by Myasthenia gravis. There are a few case reports of central causes of fluctuating ptosis. A 58-year-old man presented with fluctuating ptosis of one year duration. He was diagnosed as having ocular myasthenia and investigated. On evaluation, his electrophysiological tests revealed negative decremental response and results of neostigmine test was negative. During follow-up, patient developed headache. Imaging of the brain revealed midbrain cysticercosis granuloma. The focal encephalitis and edema was responsible for fluctuating ptosis. It is therefore essential to be aware of conditions that cause such pseudomyasthenic features. Patients with ptosis need to be evaluated for other rare central cause especially when neostigmine test is negative.

Subarachnoid basal neurocysticercosis: a focus on the most severe form of the disease

Neurocysticercosis is an endemic disease in Latin America, Asia and Africa with growing occurrence in industrialized countries due to the increase in migration from low- and middle-income to high-income countries. The most severe clinical presentation is when the parasite is located in the subarachnoid space at the base of the brain (NCSAB). Aside from its clinical presentation, the severity of this form of the disease is due to the difficulties in diagnosis and treatment. Although NCSAB frequency is lower than that reported for the parenchymal location of the parasite, its clinical relevance must be emphasized. We provide a critical review of the central epidemiological, clinical, diagnostic and therapeutic features of this particular form of the disease, which is still associated with unacceptably high rates of morbidity and mortality.

Claude's syndrome associated with neurocysticercosis

Claude's syndrome is a distinctive brainstem syndrome characterized by ipsilateral third cranial nerve palsy with contralateral hemiataxia and is due to an intrinsic or extrinsic lesion in the midbrain. We report a case of Claude's syndrome caused by neurocysticercosis infection. A 68 year-old Asian man was admitted to our hospital because of ataxia, left ptosis, and diplopia. Brain magnetic resonance imaging (MRI) showed a cystic lesion in the midbrain, which was surrounded by ring enhancement and peripheral edema. Neurocysticercosis infection was diagnosed by the cerebral spinal fluid study. The patient was treated with albendazole and steroids. A follow-up brain MRI three months later demonstrated the disappearance of a surrounding brain edema and rim enhancement. The most common cause of Claude's syndrome is cerebrovascular disease and malignancy. However, there is no report caused by neurocysticercosis infection. Therefore, if we encounter Claude's syndrome, we should consider neurocysticercosis infection as one of the etiologic factors.

Sudden-onset ptosis caused by midbrain neurocysticercosis in 2 children

Neurocysticercosis is the most common parasitic infestation of the central nervous system, which manifests commonly as acute-onset focal seizures. We report a rare nonepileptic manifestation of neurocysticercosis: midbrain neurocysticercosis presenting as sudden-onset ptosis in 2 children. To our knowledge, this has not been reported previously in children.

Atypical ophthalmological presentation of neurocysticercosis in two children

Cysticercosis is an infestation by Cysticercus cellulosae, the larval form of the cestode Taenia solium. C. cellulosae is preferentially encysted in the brain, striated muscles, and subcutaneous tissue. Seizures, hydrocephalus, meningitis, and focal symptoms caused by large cysts are the principal manifestations. Neuroophthalmologic signs are common with the meningitic and hydrocephalic manifestations of the disease. The first ophthalmologic clues of cysticercosis are typically papilloedema, pupillary abnormalities, or nystagmus. We report an atypical presentation of neurocysticercosis in two patients, with chief complaints of vertical diplopia and nystagmus.

Superior divisional oculomotor nerve palsy caused by midbrain neurocysticercosis

Superior divisional oculomotor nerve palsy caused by intrinsic brainstem disease occurs rarely. We herein report, to our knowledge, the first case of midbrain neurocysticercosis presenting as isolated superior divisional paresis of the oculomotor nerve. A 25-year-old woman presented with acute onset of headache and ptosis-upgaze palsy of the right eye. Results of the CT scan and MRI of the brain were compatible with neurocysticercosis at the left midbrain. She was dramatically responded to albendazole treatment. The diagnosis was confirmed by positive enzyme-linked immunosorbent assay (ELISA) test for cysticercus in her serum.

Metastasis to the unilateral oculomotor nucleus complex: case report

This article describes a 76 years old man that, after lung cancer surgery, showed left extrinsic oculomotor paralysis and contralateral paralysis of the superior rectus muscle associated with bilateral ptosis. Magnetic resonance imaging confirmed a rare situation characterized by an isolated metastasis in the region of the left third cranial nerve nucleus, probably compromising the superior rectus subnucleus and the central caudal nucleus, therefore justifying the bilateral oculomotor involvement.

Paralysies oculomotrices douloureuses : une approche diagnostique

We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.