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| CLINICAL IMAGE |
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| Year : 2022 | Volume
: 15
| Issue : 1 | Page : 104-106 |
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Isolated incomplete third cranial nerve palsy due to presumed cavernous sinus meningioma
Divya K Natarajan1, Mohan Kannam2, Srinivasa Perraju Ponnapalli3, Virender Sachdeva2
1 Department of Pediatric Ophthalmology, Strabismus, and Neuro-ophthalmology, Miriam Hyman Children's Eye Care Centre, Child Sight Institute, L V Prasad Eye Institute, MTC Campus, Visakhapatnam, Andhra Pradesh, India
2 Department of Pediatric Ophthalmology, Strabismus, and Neuro-ophthalmology, Nimmagadda Prasad Childrenfs Eye Care Centre, Child Sight Institute, L V Prasad Eye Institute, GMRV Campus, Visakhapatnam, Andhra Pradesh, India
3 Vijaya Medical Centre, Visakhapatnam, Andhra Pradesh, India
| Date of Submission | 29-Apr-2021 |
| Date of Decision | 29-May-2021 |
| Date of Acceptance | 31-May-2021 |
| Date of Web Publication | 02-Mar-2022 |
Correspondence Address:
Dr. Virender Sachdeva
Department of Pediatric Ophthalmology, Strabismus, and Neuro-ophthalmology, Nimmagadda Prasad Children's Eye Care Centre, Child Sight Institute, L V Prasad Eye Institute, GMRV Campus, Visakhapatnam, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_406_20
Keywords: Cavernous sinus, incomplete, isolated, meningioma, third cranial nerve palsy
How to cite this article:
Natarajan DK, Kannam M, Ponnapalli SP, Sachdeva V. Isolated incomplete third cranial nerve palsy due to presumed cavernous sinus meningioma. Oman J Ophthalmol 2022;15:104-6 |
How to cite this URL:
Natarajan DK, Kannam M, Ponnapalli SP, Sachdeva V. Isolated incomplete third cranial nerve palsy due to presumed cavernous sinus meningioma. Oman J Ophthalmol [serial online] 2022 [cited 2022 Jun 28];15:104-6. Available from: https://www.ojoonline.org/text.asp?2022/15/1/104/338890 |
 Introduction | |  |
Meningiomas are slow-growing, benign tumours that arise from the meninges anywhere in the central nervous system.[1] They are also one of the most common tumours affecting the cavernous sinus.[1] The presenting symptoms depend on the compression of the nearby neurovascular structures. Patients with cavernous sinus tumours most frequently present with diplopia, ophthalmoplegia, ptosis, trigeminal nerve dysfunction, facial numbness or facial pain, visual field defects or ischemic defects due to carotid artery involvement.[2] There are three primary treatment options for patients with cavernous sinus meningiomas: observation, microsurgical resection, and stereotactic radiosurgery.[2] However, treatment planning depends on presenting symptoms, anatomic location of the tumour, size of the tumour, disease progression and recurrence.[2] Herein, we report a case of isolated incomplete pupil involving third cranial nerve palsy as the only presenting feature of cavernous sinus meningioma.
| Case Report | | |
A 65-year-old female presented to our Neuro-ophthalmology department with gradual onset outward deviation of the right eye (RE) for 3 months. Her systemic history was significant for hypothyroidism. There was no diurnal variation of her complaints. Her best-corrected visual acuity was 20/20, N6 in the RE and 20/40, N8 in the left eye (LE). Color vision was 17/17 using Ishihara pseudo-isochromatic plates in both eyes (BE). She had mild ptosis in RE, exotropia of 25 prism diopters (PD) for distance and near in primary gaze, 7 PD in right gaze, and 20 PD in left gaze [Figure 1] and [Figure 2]. There was no exophthalmos (Hertel's exophthalmometry values of 19 mm RE and 18 mm LE) or chemosis in either eye. Ocular motility in RE showed -1 limitation of elevation and -2 limitation of adduction, while it was full in the LE [Figure 1]. Ocular examination showed minimal anisocoria with RE pupil size (3 mm) larger than LE (2 mm) [Figure 2] and no relative afferent pupillary defect in either eye. The intraocular pressure was 14 and 16 mmHg in the RE and LE, respectively. There was early cataract in BE (LE > RE). Fundus examination was normal, and automated perimetry using Humphrey visual fields (Carl Zeiss Meditec, Inc., Dublin, Ohio, USA) 24-2 Swedish interactive threshold algorithm-FAST strategy showed normal visual fields in BE. There was no other cranial nerve involvement, ataxia, or limb weakness, and sensory examination was normal. A diagnosis of isolated incomplete third cranial nerve palsy was made, localizing the lesion to subarachnoid cistern. Magnetic resonance imaging (MRI) brain and orbits with contrast showed a diffuse mass lesion in the right cavernous sinus with extension into the proximal right orbit. The lesion was isointense on T1- and T2-weighted sequences and showed diffuse enhancement following gadolinium administration [Figure 3], [Figure 4], [Figure 5]. In addition, the lesion showed thickening of the dura mater along the right temporal lobe (dural tail) [Figure 5], suggestive of intracavernous meningioma. MRI orbits showed that extraocular muscles were normal. Erythrocyte sedimentation rate, C-reactive protein, X-ray chest, and Mantoux test were either normal or negative. Lumbar puncture revealed normal opening pressure (25 cm of water). CSF analysis showed normal biochemistry and cell count. A trial of oral steroids was given to rule out any possible inflammatory pathology. There was no improvement in ocular motility or reduction in the size of the lesion. A final diagnosis of presumed cavernous sinus meningioma was made based on the neuroimaging findings. She was referred to the neurosurgeon and radiation oncologist for further intervention. Surgery was deferred in view of the lesion's close proximity to the vital structures in cavernous sinus. Radiotherapy was suggested as a favorable treatment modality, but the patient opted for observation and was kept in close follow-up. | Figure 1: Nine-gaze ocular motility photograph of the patient showing exotropia in primary gaze in the right eye (white arrow), limitation of adduction (white arrowhead), and elevation (white asterisk) in the right eye
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 | Figure 2: High magnification photograph of both eyes showing mild ptosis in the right eye (white asterisk) and mild anisocoria in the right eye (white arrowhead)
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 | Figure 3: Axial T1-weighted magnetic resonance imaging showing a diffuse lesion (white circle) in the right cavernous sinus that is isointense on this sequence
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 | Figure 4: Axial T2-weighted magnetic resonance imaging showing an isointense lesion (white circle) in the right cavernous sinus
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 | Figure 5: Axial T1-weighted postcontrast magnetic resonance imaging showing homogenous enhancing mass lesion in the right cavernous sinus (black arrow) and anterior right orbit (white arrow) and thickening along the dura mater (dural tail) along the temporal lobe (white asterisk)
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Meningiomas are usually benign, encapsulated tumors that cause symptoms due to the mass effect on adjoining structures.[3] Meningiomas of the cavernous sinus may infiltrate the surrounding cranial nerves, internal carotid artery, and rarely, the optic nerve and pituitary gland.[4] Patients might present with multiple cranial neuropathies and/or vascular involvement causing conjunctival congestion, proptosis, and ophthalmoplegia.[2]
Due to their location, it is difficult to obtain tissue biopsy or resect the tumor.[5] Diagnosis is established based on classical neuroimaging findings and excluding other inflammatory/neoplastic lesions by laboratory and CSF analysis. The diffusely enhancing cavernous sinus lesion on contrast with thickening of dura mater (dural tail) on neuroimaging is highly suggestive of meningioma.[6]
Unique feature in our case was that the lesion presented with only isolated incomplete third nerve palsy, without other neurological disturbances. Only clue to compressive etiology was minimal anisocoria.
Our case highlights the clinical presentation and classical radiological features and presentation of cavernous sinus meningioma as an isolated incomplete third nerve palsy with minimal anisocoria and even without presentation like a full-blown sphenocavernous syndrome.
Acknowledgments
We thank our diagnostic and photographic teams of L V Prasad Eye Institute, GMRV Campus, for their support in patient management and documentation of the clinical pictures and investigations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Hyderabad Eye Research Foundation, Hyderabad, India
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 3. | Alyamany M, Alshardan MM, Jamea AA, ElBakry N, Soualmi L, Orz Y. Meningioma consistency: Correlation between magnetic resonance imaging characteristics, operative findings, and histopathological features. Asian J Neurosurg 2018;13:324-8. [ PUBMED] [Full text] |
| 4. | Umansky F, Nathan H. The lateral wall of the cavernous sinus. With special reference to the nerves related to it. J Neurosurg 1982;56:228-34. |
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| 6. | Goldsher D, Litt AW, Pinto RS, Bannon KR, Kricheff II. Dural “tail” associated with meningiomas on Gd-DTPA-enhanced MR images: Characteristics, differential diagnostic value, and possible implications for treatment. Radiology 1990;176:447-50. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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