Romanian Neurosurgery (2019) XXXIII (2): pp. 188-190 DOI: 10.33962/roneuro-2019-035 www.journals.lapub.co.uk/index.php/roneurosurgery Post traumatic isolated ipsilateral oculomotor nerve palsy. An uncommon presentation Praveen Kumar1, Sharad Pandey2, Kulwant Singh1, Mukesh Sharma1, Prarthana Saxena2 1 Department of Neurosurgery, Sir Sunder Lal Hospital, IMS, BHU, Varanasi, Uttar Pradesh, INDIA 2 Department of Neurosurgery, P.G.I.M.E.R. Dr Ram Manohar Lohia Hospital, New Delhi, INDIA ABSTRACT The common causes of isolated third nerve palsy are microvascular infarction, intracranial aneurysm, diabetes, hypertension and atherosclerosis. Here we are presenting a case of 26-year female presenting with a history of head injury two months back. She presented with ptosis on the left side. On computed tomography, a large left-sided chronic subdural hematoma with significant midline shift was found. Isolated ipsilateral third nerve palsy is a rare presentation with unilateral chronic subdural hematoma. Improvement in ptosis after surgery indicate a good neurological outcome. INTRODUCTION Chronic subdural Hematoma is a collection of liquefied old blood between the duramater and arachnoid membrane of brain. It is first described by Virchow as “Pachymeningitis hemorrhagic interna “in 1857. Later Trotter put forward the theory of traumatic rupture of bridging veins as a cause of what he named “subdural hemorrhagic cyst” Chronic SDH is commonly present in elderly patients After a trivial Trauma [1,2]. Unilateral chronic SDH is more common in comparison to bilateral SDH [3]. Chronic SDH is a common presentation in people taking anticoagulant or antiplatelet drugs. Commonly Chronic SDH Patients present with Headache, Vomiting, Hemiparesis, Ataxia, Altered Consciousness, Seizures, Urinary incontinence [4]. Patients with Chronic SDH rarely present with vertigo and nystagmus upward gaze palsy, and isolated third nerve palsy [5,6,7]. Isolated third nerve palsy presented with ptosis is rare presentation in post-traumatic chronic SDH patients. CASE REPORT We are presenting a 26-year-old female patient, non-hypertensive, Keywords ptosis, third nerve palsy, chronic subdural hematoma (chronic SDH) Corresponding author Sharad Pandey Department of Neurosurgery, P.G.I.M.E.R. Dr Ram Manohar Lohia Hospital, New Delhi. India drsharad23@yahoo.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published June 2019 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 189 Post traumatic isolated ipsilateral oculomotor nerve palsy non diabetics, not on antiplatlet drugs. She presented with history of Head Injury two months back. No initial CT Head was done at the time of injury. Patient was conscious, cooperative and well orientated at the time of admission. Patient’s vitals were within normal limit. All hematological investigations were normal. She presented with complaining of headache after one month of head injury, headache was not severe in nature and relieving on taking analgesic. There was no vomiting, hemiparesis, gait disturbance and urinary incontinence. After one and half month of head injury she complaining of dropping of left upper eyelid and patient vision was 6/9 in left eye. Left eyeball was placed outward and downward due to loss of adduction and elevation [FIGURE 1]. Left side pupil was mid dilated but fundus examination was normal. A CT Head was done showing large left side fronto-temporo-parietal chronic subdural hema- toma with significant midline shift [FIGURE 2]. Patient was taken up for left sided two burr hole drainage of subdural hematoma under general anesthesia. Post operatively patient has no significant complaints and patient was put on antiepileptic medications. Her Neurological and clinical condition improved after surgery. Patient left eye ptosis and eyeball position improved same day after the surgery. Patient discharge from the hospital after 3 days in a stable condition. Improvement in ptosis after surgery indicates good neurological outcome and this was due to brainstem compression and transtentorial (Uncal) herniation which cause compression of oculomotor nerve. FIGURE 1. (A) severe ptosis of left eye with outward & downward displacement of eyeball (B) pre- operative CT head showing left fronto-temporo-parietal chronic subdural hematoma with significant midline shift and mass effect. FIGURE 2. (A) Postoperative improvement in ptosis & position of eyeball (B) postoperative CT showing no residual hematoma. DISCUSSION Oculomotor nerve supplies all the extaocular muscle of eye except superior oblique and lateral rectus muscle. It also supplies the striated muscle of the levator palpebrae superioris and the smooth muscle concerned with accommodation namely the sphincter papillae and ciliary muscle. In a complete lesion of the nerve the eye movement restricted in upward, downward and inward direction. Patient complaining of diplopia. There is drooping of upper eyelid due to paralysis of levator palpebrae superioris. Chronic subdural hematoma represents one of the most frequent intracranial hemorrhages encountered in the neurosurgical department, with elderly people being more frequently affected [8]. In an elderly patient brain undergo atrophied leads to 11% increase in extra cerebral space [9]. The other predisposing factors are head injury, alcohol abuse, coagulopathic disorder, antiplatlet drugs [10]. A history of head injury due to trivial trauma is presented in 60- 80% of the elderly patients [11, 12]. Most of the patient presented with complaining of headache, vomiting & hemiparesis. Isolated Third nerve palsy presented with ptosis is a rare presentation. The most common causes of isolated Third Nerve Palsy are microvascular infarction, intracranial aneurysm, Diabetes, Hypertension, Atherosclerosis. (13, 14) CONCLUSION Ipsilateral third nerve palsy in post-traumatic unilateral chronic subdural hematoma is a rare condition. Improvement in ptosis after surgery indicates good neurological outcome as in large chronic subdural hematoma brain shift to opposite site leads to brainstem compression and transtentorial (Uncal) herniation which cause compression of oculomotor nerve [15] FINANCIAL SUPPORT AND SPONSORSHIP Nil CONFLICT OF INTEREST There are on conflicts of interest. REFERENCES 1. Adhiyaman V., Asghar M., Ganeshram K.N., Bhowmick B.K. Chronic subdural haematoma in the elderly. Postgrad Med J. 2002 Feb;78(916):71–75. 190 Praveen Kumar, Sharad Pandey, Kulwant Singh et al. 2. Arpino L., Gravina M., Basile D., Franco A. Spontaneous chronic subdural hematoma in a young adult. J Neurosurg Sci. 2009 Jun;53(2):55–57. 3. Nayil K, Ramzan A, Sajad A, Zahoor S, Wani A, et al. (2012) Subdural Hematomas: An Analysis of 1181 Kashmiri Patients. World Neuro¬surg 77(1): 103-110. 4. 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