Cargando…

SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy

Background: Cranial nerve palsies (CNP) in association with a hypophyseal process can be uni/bilateral, single, multiple, with or without visual deficits and pain. It is reported 14-30% of pituitary tumors lead to a palsy. Often the acute cause of palsy is apoplexy (1) but other rare etiologies exis...

Descripción completa

Detalles Bibliográficos
Autor principal: Magar, Maria
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7208906/
http://dx.doi.org/10.1210/jendso/bvaa046.2190
_version_ 1783530955815780352
author Magar, Maria
author_facet Magar, Maria
author_sort Magar, Maria
collection PubMed
description Background: Cranial nerve palsies (CNP) in association with a hypophyseal process can be uni/bilateral, single, multiple, with or without visual deficits and pain. It is reported 14-30% of pituitary tumors lead to a palsy. Often the acute cause of palsy is apoplexy (1) but other rare etiologies exist such as abscess or prolactinoma (2, 3). Clinical Case: A 40 year old woman with no PMH presented to the ED for acute on chronic headaches. Two days prior she started having blurry vision in her R eye. The headache improved with medications and she was sent home. Two days later she returned with new symptoms of the R eye deviating laterally and down, associated ptosis and a 6 mm nonreactive pupil. A stat MRI brain was obtained for her new CN III palsy, showing a 1.4 cm sellar mass with suprasellar extension. Further history revealed that two months prior her regular menses had stopped. Labs were obtained that included a prolactin 127 (nl 4.8-23.3); fT4 1.2 (nl .93-1.7); IGF1 129 (nl 52-328); 9 am cortisol 16.6 (nl 4-22); FSH 5.5 (nl 3.5-12.5); LH 3.8 (nl 2.4-12.6). Neurosurgery (NSGY) was consulted, recommending a trial of medical therapy since her visual fields were intact. Endocrine then advised cabergoline 0.5 mg twice weekly. In NSGY clinic ten days later, her prolactin was 0.2 but her symptoms remained the same. One month later, she was seen in Neuro-ophthalmology clinic where it was noted that her diplopia had subjectively resolved. Her eye exam was documented as normal except for sluggish pupils. Conclusion: CNP are more common in larger pituitary tumors and often associated with panhypopituitarism and necrosis. About 90% of cases resolve by one year after pituitary surgery. Although our patient had a tumor that was slightly larger than 1 cm, she did not need hormonal replacement, did not have hemorrhage/necrosis, and her symptoms resolved with a dopamine agonist. There is one other case in the literature of medically treated macroprolactinoma with resolution of CN III palsy (3). References: (1) Hage R, et al. Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy. World Neurosurgery. 2016; 94:447-452.(2) Wang L, et al. Pituitary abscess resulting in isolated abducens palsy. Journal of the Formosan Medical Association. 2016;115:134-135.(3) Harries A, et al. Resolution of third nerve palsy following treatment of prolactinoma with cabergoline. Acta Neurochir. 2010; 152:1741-1743.
format Online
Article
Text
id pubmed-7208906
institution National Center for Biotechnology Information
language English
publishDate 2020
publisher Oxford University Press
record_format MEDLINE/PubMed
spelling pubmed-72089062020-05-13 SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy Magar, Maria J Endocr Soc Neuroendocrinology and Pituitary Background: Cranial nerve palsies (CNP) in association with a hypophyseal process can be uni/bilateral, single, multiple, with or without visual deficits and pain. It is reported 14-30% of pituitary tumors lead to a palsy. Often the acute cause of palsy is apoplexy (1) but other rare etiologies exist such as abscess or prolactinoma (2, 3). Clinical Case: A 40 year old woman with no PMH presented to the ED for acute on chronic headaches. Two days prior she started having blurry vision in her R eye. The headache improved with medications and she was sent home. Two days later she returned with new symptoms of the R eye deviating laterally and down, associated ptosis and a 6 mm nonreactive pupil. A stat MRI brain was obtained for her new CN III palsy, showing a 1.4 cm sellar mass with suprasellar extension. Further history revealed that two months prior her regular menses had stopped. Labs were obtained that included a prolactin 127 (nl 4.8-23.3); fT4 1.2 (nl .93-1.7); IGF1 129 (nl 52-328); 9 am cortisol 16.6 (nl 4-22); FSH 5.5 (nl 3.5-12.5); LH 3.8 (nl 2.4-12.6). Neurosurgery (NSGY) was consulted, recommending a trial of medical therapy since her visual fields were intact. Endocrine then advised cabergoline 0.5 mg twice weekly. In NSGY clinic ten days later, her prolactin was 0.2 but her symptoms remained the same. One month later, she was seen in Neuro-ophthalmology clinic where it was noted that her diplopia had subjectively resolved. Her eye exam was documented as normal except for sluggish pupils. Conclusion: CNP are more common in larger pituitary tumors and often associated with panhypopituitarism and necrosis. About 90% of cases resolve by one year after pituitary surgery. Although our patient had a tumor that was slightly larger than 1 cm, she did not need hormonal replacement, did not have hemorrhage/necrosis, and her symptoms resolved with a dopamine agonist. There is one other case in the literature of medically treated macroprolactinoma with resolution of CN III palsy (3). References: (1) Hage R, et al. Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy. World Neurosurgery. 2016; 94:447-452.(2) Wang L, et al. Pituitary abscess resulting in isolated abducens palsy. Journal of the Formosan Medical Association. 2016;115:134-135.(3) Harries A, et al. Resolution of third nerve palsy following treatment of prolactinoma with cabergoline. Acta Neurochir. 2010; 152:1741-1743. Oxford University Press 2020-05-08 /pmc/articles/PMC7208906/ http://dx.doi.org/10.1210/jendso/bvaa046.2190 Text en © Endocrine Society 2020. http://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
spellingShingle Neuroendocrinology and Pituitary
Magar, Maria
SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy
title SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy
title_full SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy
title_fullStr SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy
title_full_unstemmed SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy
title_short SAT-LB51 The Unique Etiology and Management of a Third Cranial Nerve Palsy
title_sort sat-lb51 the unique etiology and management of a third cranial nerve palsy
topic Neuroendocrinology and Pituitary
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7208906/
http://dx.doi.org/10.1210/jendso/bvaa046.2190
work_keys_str_mv AT magarmaria satlb51theuniqueetiologyandmanagementofathirdcranialnervepalsy