CN palsy management

 

nonisolated 3rd nerve palsy:

MRI with and without gad, likely not

LP to look for meningeal process

 

Isolated 3rd nerve palsy (regardless of pain):

divide into age

if <50:  MRI, consider myesthenia gravis, LP, angiogram

if >50:  divide into pupil involved or not

if pupil sparing:  likely microvascular, can watch, consider screen with ESR, CRP, HgA1c, RPR, consider myesthenia gravis -- need to have pupil watched.  If not better by 3 weeks, then do pupil involved w/u

if partial 3rd nerve, or complete, either with pupil involved:

MRI with gad--> if no answer, move to MRA or angiogram

 

nomenclature:

partial - only some muscles involved

incomplete - all muscles involved, just little

 

Management of IVth nerve palsy:

congenital or acquired? can do vertical conversion amplitude

trauma or no trauma?

then divide into isolated vs. nonisolated

if isolated, <50:  MRI, consider MG, maybe LP

>50: observe, esr, crp, hga1c, RPR, MG, watch

 

6th nerve palsy:

isolated vs. nonisolated

if isolated, divide into bilateral vs. unilateral

if bilateral:  can be meningeal process, carcinoma, or inc ICP--> MRI, think MG, thyroid, LP almost always

unilateral:  if >50 or less

<50:  MRI, ?LP, think MG

>50:  observe, esr, RPR, Hga1c, think MG, watch