About OJO | Search | Ahead of print | Current Issue | Archives | Author Instructions | Reviewer Guidelines | Online submissionLogin 
Oman Journal of Ophthalmology Oman Journal of Ophthalmology
  Editorial Board | Subscribe | Advertise | Contact
https://www.omanophthalmicsociety.org/ Users Online: 302  Wide layoutNarrow layoutFull screen layout Home Print this page  Email this page Small font size Default font size Increase font size

 Table of Contents    
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 103-104  

Complete third nerve palsy: Only presenting sign of extradural hematoma in an awake patient

Department of Neurosurgery, Lokmanya Tilak Muncipal Medical College and Muncipal General Hospital, Sion, Mumbai, India

Date of Web Publication19-Jul-2014

Correspondence Address:
Batuk Diyora
Department of Neurosurgery, L. T. M. G. Hospital, Sion (W), Mumbai - 400 022
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-620X.137177

Rights and Permissions

How to cite this article:
Diyora B, Kukreja S, Nayak N, Kamble H, Sharma A. Complete third nerve palsy: Only presenting sign of extradural hematoma in an awake patient. Oman J Ophthalmol 2014;7:103-4

How to cite this URL:
Diyora B, Kukreja S, Nayak N, Kamble H, Sharma A. Complete third nerve palsy: Only presenting sign of extradural hematoma in an awake patient. Oman J Ophthalmol [serial online] 2014 [cited 2023 Mar 30];7:103-4. Available from: https://www.ojoonline.org/text.asp?2014/7/2/103/137177


Complete third nerve palsy due to extradural hematoma in an awake patient is a contrasting clinical feature and an extremely rare clinical entity.

A 28-year-female presented with a sudden-onset, painless, complete left third nerve palsy. She had a fall in the bathroom four weeks ago. At the time of the fall, she was pregnant and was asymptomatic. Two weeks after the fall, she had an uneventful normal vaginal delivery. One week post partum, she developed diplopia and noticed drooping of the left eyelid, which was painless. She consulted an ophthalmologist who asked for a magnetic resonance imaging (MRI) of the brain and referred the patient to the neurosurgery department.

She had no headache. She was fully conscious and well oriented to time, place, and person. The left pupil was 5 mm in size and not reacting to light. The right was 3 mm in size and briskly reacting to the light. External ocular movement examination revealed left medial rectus palsy [Figure 1]. Fundoscopic examination revealed no abnormality. No other positive finding was observed. MRI of the brain revealed a 7.5 × 3.5 × 6 cm-sized extradural hematoma in the left temporal region, which was iso to hyperintense on T1- and hyperintense on T2-weighted images with effacement of the nearby temporal lobe. Clot age of about 7 to 10 days was confirmed on MRI findings [Figure 2].
Figure 1: Preoperative clinical photograph showing (a) left-sided ptosis, (b) restricted adduction movement of left eyeball, and (c) normal abduction movement of left eyeball suggestive of left-sided isolated third nerve palsy

Click here to view
Figure 2: Magnetic resonance (MR) image of brain showing extradural hematoma in the left temporal fossa significantly compressing the ipsilateral temporal lobe. Hematoma showed central hypointensity and peripheral hyperintensity on T1-weighted images and homogeneous hyperintensity on T2-weighted images

Click here to view

She underwent left temporal craniotomy. About 150 mL of solid/liquid blood was drained out. No source of bleeding was found. Diplopia improved postoperatively. At the end of two weeks, near-complete improvement in ptosis and significant improvement in adduction was achieved [Figure 3]. Pupillary size became normal at six weeks.
Figure 3: Postoperative clinical photograph showing (a) near-complete improvement of ptosis, (b) improved adduction movement of left eyeball, and (c) normal adduction movement of left eyeball

Click here to view

Traumatic expanding subdural hematomas may present with third nerve involvement and are usually accompanied by additional neurological dysfunction. In an awake patient, complete third nerve paralysis due to intracranial hematomas is rare, and all of them have been associated with subdural hematoma. [1],[2] Ramirez et al. have reported a case of second, third, and fourth cranial nerve paresis as the only evidence of a recurrent epidural hematoma. [3] Only one case of complete third nerve paralysis and epidural hematoma in an awake patient without any other neurological signs or symptoms has been reported. [4]

Epidural hematomas occur rapidly and are usually stable, attaining maximum size within minutes of injury. We believe that isolated complete third nerve palsy without any other signs or symptoms in our patient was due to the slowly developing extradural hematoma of venous origin displacing the temporal lobe and causing compression of the third nerve.

Dilated, sluggish, or fixed pupil (s), bilateral or ipsilateral to the injury occur due to increased intracranial pressure (ICP) or transtentorial herniation. Raised ICP can also have other signs like hypertension, bradycardia, and bradypnea. Transtentorial herniation has the triad of coma, fixed and dilated pupil (s), and decerebrate posturing. In our patient, fundoscopic examination was normal, ruling out raised ICP. Also, transtentorial herniation would have presented with other neurological symptoms, which were absent in our patient. Epidural hematoma accompanied by oculomotor nerve palsy may also occur due to sphenoid sinusitis. [5],[6] Stretching of the ipsilateral third nerve initially causes compression of pupilloconstrictor fibers with subsequent paralytic mydriasis. As the uncal herniation progresses, ptosis and weakness of the medial rectus muscle follows sequentially.

Patients presenting with isolated third nerve palsy must undergo brain imaging to rule out extradural hematoma. Physicians must be aware of this unusual and treatable cause of isolated third nerve paralysis, as early intervention in such cases results in complete recovery.

   References Top

1.Clark ES, Gooddy W. Ipsilateral third cranial nerve palsy as a presenting sign in acute subdural haematoma. Brain 1953;76:266-78.  Back to cited text no. 1
2.Pevehouse BC, Bloom WH, McKissock W. Ophthalmologic aspects of diagnosis and localization of subdural hematoma. An analysis of 389 cases and review of the literature. Neurology 1960;10:1037-41.  Back to cited text no. 2
3.Ramirez RE, Hibri N, Brennan MW. Recurrent subtemporal epidural hematoma with second, third and fourth cranial nerve compression. Comput Radiol 1984;8:37-41.  Back to cited text no. 3
4.DiTullio MV Jr. Epidural hematoma with complete third nerve paralysis in an awake patient. Surg Neurol 1977;7:193-4.  Back to cited text no. 4
5.Cho KS, Cho WH, Kim HJ, Roh HJ. Epidural hematoma accompanied by oculomotor nerve palsy due to sphenoid sinusitis. Am J Otolaryngol 2011;32:355-7.  Back to cited text no. 5
6.Stefanis L, Przedborski S. Isolated palsy of the superior branch of the oculomotor nerve due to chronic erosive sphenoid sinusitis. J Clin Neuroophthalmol 1993;13:229-31.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Fixed, Dilated, and Conversing—Unreactive Pupil With Preserved Consciousness Indicating Acutely Rising Intracranial Pressure due to Traumatic Intraparenchymal Contusions: Case Report and Review of the Literature
Malia McAvoy, Gina Lee, Scott Boop, Madeline E. Greil, Kayla A. Durler, Christopher C. Young, Lindy Craft, Randall M. Chesnut, Sarah Wahlster
The Neurohospitalist. 2021; : 1941874421
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Figures

 Article Access Statistics
    PDF Downloaded223    
    Comments [Add]    
    Cited by others 1    

Recommend this journal