University of Southern California Medical School, Los Angeles, California, USA.
Can J Neurol Sci. 2010 Sep;37(5):662-70. doi: 10.1017/s0317167100010866.
Most studies of third nerve palsy (TNP) antedate computerized imaging and focus primarily on chart review of referral outpatients.
To compare a large contrasting population, I reviewed 1400 personally-examined municipal hospital inpatients with TNPs seen over 37 years.
TNPs were bilateral in 11%, complete in 33%, without other neurological signs (isolated) in 36%, and associated with recurrent cranial neuropathies in 7%. Third nerve damage occurred in the subarachnoid space in 32%, the cavernous sinus in 23%, the brainstem in 14%, as a nonlocalized peripheral neuropathy in 18% and at an uncertain location in 13%. Causes were trauma (26%), tumor (12%), diabetes (11%), aneurysm (10%), surgery (10%), stroke (8%), infection (5%), Guillain-Barre and Fisher syndromes (5%), idiopathic cavernous sinusitis (3%), benign self-limited (2%), miscellaneous (4%), and unknown (3%). Local causes, besides an abundance of trauma, included six cases involving cysticercosis, four with wound botulism, and one with coccidiomycotic meningitis. Of 234 patients with diabetes, microvascular ischemia was the cause of TNP in only two-thirds (five had aneurysms) and 53% of those with diabetic microvascular ischemia had pupillary involvement-often bilateral, suggesting concomitant autonomic neuropathy. Only 2% of aneurysms spared the pupil. Apainful onset occurred with 94% of aneurysm and 69% of diabetic cases.
Bilateral TNPs, multiple cranial neuropathies, and accompanying neurological signs were common among our inpatients, as were causes rare in outpatient settings such as severe trauma, transtentorial herniation, midbrain strokes, and the Guillain-Barre syndrome. Few cases remained undiagnosed and nondiabetic ischemia was rare.
大多数关于第三颅神经麻痹（TNP）的研究都早于计算机成像技术，主要侧重于对外诊患者的图表回顾。
为了比较一个大型的对比人群，我回顾了 37 年来在市政医院就诊的 1400 名患有 TNP 的住院患者。
11%的 TNP 为双侧，33%为完全性，36%为无其他神经体征（孤立性），7%为与复发性颅神经病变相关。第三神经损伤发生在蛛网膜下腔的占 32%，海绵窦的占 23%，脑干的占 14%，作为非局灶性周围神经病的占 18%，位置不确定的占 13%。病因包括创伤（26%）、肿瘤（12%）、糖尿病（11%）、动脉瘤（10%）、手术（10%）、中风（8%）、感染（5%）、吉兰-巴雷和费舍尔综合征（5%）、特发性海绵窦炎（3%）、良性自限性（2%）、杂项（4%）和未知（3%）。除了大量创伤外，局部病因还包括六例囊虫病、四例破伤风和一例球孢子菌性脑膜炎。在 234 名糖尿病患者中，仅有三分之二（五例有动脉瘤）的 TNP 是由微血管缺血引起的，而有糖尿病微血管缺血的患者中 53%的瞳孔受累——通常是双侧的，提示同时存在自主神经病变。只有 2%的动脉瘤不影响瞳孔。94%的动脉瘤和 69%的糖尿病患者的 TNP 为急性起病。
在我们的住院患者中，双侧 TNP、多发性颅神经病变和伴随的神经体征很常见，而在门诊环境中很少见的病因，如严重创伤、颅后窝疝、中脑卒中和格林-巴利综合征也很常见。很少有病例仍未确诊，非糖尿病性缺血也很少见。
