Prolactinoma presenting with intermittent third nerve palsy

Neuro-ophthalmologic exploration in non-functioning pituitary adenoma

Non-functioning pituitary adenoma may lead to blindness and causes visual impairment in 58% of cases and, more rarely, ocular motor disorder. Patients are slow to become aware of their visual dysfunction, vision in one eye compensating the deficit in the other. Assessment of visual function, comprising visual acuity and visual field evaluation and fundus examination, should be performed regularly according to the severity of impairment. Optic nerve optical coherence tomography (OCT) can quantify optic atrophy reproducibly, and is of prognostic value for postoperative visual recovery. Diplopia most often involves decompensation of heterophoria, visual field fusion being hampered by the visual field defect; such diplopia without ocular motor deficit is known as "hemifield slide". Diplopia associated with ocular motor palsy is caused by tumoral invasion of the cavernous sinus (IIIrd, IVth or VIth nerve palsy); in large impairment, restricted eye movement is easily observed; milder palsies require neuro-ophthalmologic assessment and/or Lancaster test. Pituitary apoplexy induces ocular motor impairment in 70% of cases, strongly guiding diagnosis. Visual impairment is associated in 75% of cases. The degree of neuro-ophthalmologic (visual and ocular motor) impairment is one of the main criteria guiding treatment of pituitary apoplexy (conservative medical and/or surgical treatment) and follow-up.

Temporary bilateral oculomotor nerve palsy as the sole presenting sign of a pituitary mass

A 65-year-old patient presented with isolated bilateral third nerve palsy. Neuroimaging demonstrated a 2 cm pituitary mass with extension into the cavernous sinus on the right. The patient went on to experience spontaneous complete resolution of symptoms with associated radiological shrinkage of the mass. Bilateral third nerve palsy is a very rare presenting sign, with only one previous case reported in the literature secondary to a pituitary adenoma. Spontaneous resolution of non-functioning pituitary tumours is reported to occur in approximately 10% of cases. However, there are only a small number of reports to date involving spontaneous regression of tumours with corresponding resolution of cranial nerve palsies.

Painful vertical diplopia as a presentation of a pituitary mass

BACKGROUND

Pituitary tumours may present with a variety of neurological and endocrinological signs and symptoms. It is very rare however for them to present with sudden onset painful diplopia. The current literature and possible mechanisms for this are discussed.

CASE PRESENTATION

We describe a case of a pituitary mass which presented with sudden onset painful diplopia with an associated restricted pattern on Lees Chart testing. This led to an initial working diagnosis of orbital myositis.

CONCLUSION

Awareness of different modes of presentation of pituitary lesions is important so that appropriate imaging may be requested and delay in diagnosis prevented.

Pseudomyasthenia resulting from a posterior carotid artery wall aneurysm: a novel presentation: case report

OBJECTIVE AND IMPORTANCE

Painful oculomotor palsy can result from enlargement or rupture of intracranial aneurysms. The IIIrd cranial nerve dysfunction in this setting, whether partial or complete, is usually fixed or progressive and is sometimes reversible with surgery. We report an unusual oculomotor manifestation of a posterior carotid artery wall aneurysm, which mimicked ocular myasthenia gravis.

CLINICAL PRESENTATION

A 47-year-old woman developed painless, intermittent, partial IIIrd cranial nerve palsy. She presented with isolated episodic left-sided ptosis, which initially suggested a metabolic or neuromuscular disorder. However, digital subtraction angiography revealed a left posterior carotid artery wall aneurysm, just proximal to the origin of the posterior communicating artery.

INTERVENTION

The aneurysm was successfully clipped via a pterional craniotomy. During surgery, the aneurysm was observed to be compressing the oculomotor nerve. The patient's symptoms resolved after the operation.

CONCLUSION

The variability of incomplete IIIrd cranial nerve deficits can present a diagnostic challenge, and the approach for patients with isolated IIIrd cranial nerve palsies remains controversial. Although intracranial aneurysms compressing the oculomotor nerve classically produce fixed or progressive IIIrd cranial nerve palsies with pupillary involvement, anatomic variations may result in atypical presentations. With the exception of patients who present with pupil-sparing but otherwise complete IIIrd cranial nerve palsy, clinicians should always consider an intracranial aneurysm when confronted with even subtle dysfunction of the oculomotor nerve.

An imaging guide to the evaluation of third cranial nerve palsies

PURPOSE

To devise a cost-effective imaging guide for the evaluation of third nerve palsies (TNP), based on an extensive review of the literature.

METHODS

A review of the pertinent English language literature was performed to devise a guideline for the evaluation and neuroimaging of TNP. The authors also report a retrospective review of the cost of imaging studies performed on 91 patients with TNP.

RESULTS

On the basis of the available literature, an imaging guide was developed and applied to a retrospective chart review of 91 patients from a single tertiary care center (Baylor College of Medicine). The cost effectiveness as well as the efficacy of the imaging guide was analyzed.

CONCLUSIONS

The evaluation of TNP can be difficult; however, using such guides may allow for more appropriate and cost-effective evaluation of these patients.

Pituitary apoplexy presenting as multiple ocular nerve palsies of sudden onset

An acromegalic patient with pituitary apoplexy presented with multiple ocular nerve palsies with full visual fields. High resolution CT confirmed a pituitary tumour. We believe this clinical combination to be unique.

Ptosis as the early manifestation of pituitary tumour

Three patients who developed unilateral ptosis followed by partial third nerve palsy were found to have a pituitary tumour. The visual field defects were minimal and asymptomatic. Two patients had a chromophobe adenoma and one patient had a prolactinoma. The importance of recognising a pituitary tumour as the cause of acquired unilateral ptosis is emphasised.

Diagnostic work-up of hyperprolactinemic disorders

Substantial advances have been made in the understanding of chronic hyperprolactinemia. The diagnostic effort should be directed at excluding physiological and pharmacological causes of chronic hyperprolactinemia, both of which are reversible and are not likely to be of grave consequence. Subsequently further efforts should be made to rule out obvious pathological entities, in particular, treatable hypothyroidism. Finally, the diagnosis of prolactinoma must be entertained. It relies on the biochemical determination of prolactin as well as direct imaging of the pituitary.