Complete Third Nerve Palsy: A Rare Occurrence in Fulminant IIH Case Report
Hesham Eisa1, Yash Nene1, Deborah Bradshaw2
1SUNY Upstate, 2SUNY Upstate Medical University
Objective:
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Background:
Idiopathic Intracranial Hypertension (IIH) is a condition marked by increased intracranial pressure without a known cause. Typical symptoms include headaches, vision loss, transient visual obscurations (TVOs), diplopia (usually due to sixth nerve palsy),divergence insufficiency, and pulsatile tinnitus. Atypical presentations may include asymmetric or unilateral papilledema, third and fourth nerve palsies, internuclear ophthalmoplegia. Fulminant IIH, a more severe variant, is characterized by rapid vision loss over a few days. This case report details a rare presentation of fulminant IIH with complete unilateral third nerve palsy.
Design/Methods:

A 29-year-old woman with a BMI of 36 and no significant medical history presented with worsening headaches, nausea, and blurred vision for one week. She had bilateral papilledema and reduced visual acuity. Initial imaging, including  CTA and CTV, showed no significant abnormalities. MRI revealed bilateral posterior scleral flattening, indicative of papilledema. A lumbar puncture confirmed elevated cerebrospinal fluid pressure (>55 cm H2O), leading to the diagnosis of IIH. She was treated with acetazolamide and discharged. Two days later, the patient returned with right-sided ptosis, mydriasis, and complete third nerve palsy. Despite repeat imaging, no structural causes like aneurysms were found. Acetazolamide was discontinued due to concerns over low cerebrospinal fluid pressure, but her vision deteriorated further, becoming limited to finger counting. Repeat LP reconfirmed elevated opening pressure and repeat MRI showed significant venous congestion suggestive of ongoing intracranial hypertension. Intravenous acetazolamide and methylprednisolone were administered, and a lumbar drain was placed, resulting in significant improvement. Eventually, a ventriculoperitoneal shunt was inserted, leading to rapid recovery from ptosis, ophthalmoplegia, and headaches.

Results:
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Conclusions:
This case underscores the importance of recognizing IIH in patients presenting with headaches and cranial nerve palsies, particularly when imaging shows no structural abnormalities.The rare occurrence of third nerve palsy suggests the potential severity of IIH.Surgical intervention may be necessary when medical treatments fail.
10.1212/WNL.0000000000211580
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