Bilateral third nerve palsy in basilar vertebral artery disease. Report of three cases with survival and review of the literature

Bilateral Fascicular Third Nerve Palsy in Posterior Circulation Stroke

Third nerve palsy is bilateral in only about 10% of cases, of which one in five cases is due to brainstem stroke. Bilateral oculomotor nerve palsy as an isolated clinical finding after brainstem stroke is extremely rare. We present a case of severe bilateral fascicular oculomotor nerve palsy due to distal basilar occlusion and subsequent midbrain infarction of cardioembolic origin. The patient required mechanical aids and subsequent ptosis surgery to relieve complete ptosis at least unilaterally.

Posttraumatic pneumocephalus-induced bilateral oculomotor nerve palsy

Bilateral third nerve palsy often points to the involvement of its nucleus. Third nerve palsy as a result of posttraumatic nuclear involvement is an extremely rare condition. A 23-year-old man presented with a depressed skull fracture after acute head trauma and had Glasgow Coma Scale Score of 9. The diameters of the pupils were 6.5 and 7.5 mm and they were not reactive to light stimulation. There was bilateral ptosis. Computed tomography (CT) relieved bilateral perimesensephalic pneumocephalus. We suggested that bilateral oculomotor nerve paresis might develop in association with posttraumatic bilateral perimesensephalic pneumocephalus, which affected the nucleus of the third nerve.

Nemaline myopathy: an unusual cause of ophthalmoparesis

Ophthalmoparesis and ptosis are extremely rare in nemaline myopathy. A 45-year-old man with a long history of bilateral ptosis and a 1-year history of diplopia is reported. Leg and arm weakness and wasting had been present since childhood, with a very slow deterioration over time. On examination, there was nonfatigueable bilateral ptosis that was more marked on the right. There was diplopia on left gaze. Extraocular movements showed limitation of elevation and adduction of the right eye. There was bilateral facial weakness, as well as proximal and distal wasting and weakness in the arms and legs. Electromyography (EMG) showed a combination of myopathic and neurogenic changes. Triceps muscle biopsy showed small multiple collections of rod-like structures in > 50% of fibers. This patient presented with a clinical picture that did not primarily suggest nemaline myopathy. This case illustrates the heterogeneity of this disorder and the need for muscle biopsy to make an accurate diagnosis in patients with ptosis and progressive external ophthalmoparesis.