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      Nothnagel Syndrome Without Extremity Symptoms: A Case Report

      case-report
      1 , , 1 , 2
      ,
      Cureus
      Cureus
      diabetes mellitus, neurology, neuro-ophthalmology, physical exam, stroke, third nerve palsy

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          Abstract

          The finding of pupil-sparing third nerve palsy is synonymous with diabetic third nerve palsy in the minds of many clinicians. While this is the most common cause of a third nerve palsy with normal pupillary response, it is not the only cause. We present the case of an elderly diabetic gentleman who presented with pupil-sparing third nerve palsy and gait abnormalities without any weakness or incoordination in the extremities. He was initially diagnosed with a third cranial nerve mononeuropathy due to poorly controlled type 2 diabetes but was later found on MRI to have a small ischemic stroke in the dorsal midbrain. This case highlights the importance of a thorough neurological examination and the findings in such an exam that should prompt clinicians to consider etiologies other than diabetes in patients presenting with a pupil-sparing third nerve palsy. As discussed below, failure to recognize these differential diagnoses can result in poor outcomes for patients.

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          Most cited references16

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          Incidence and Etiologies of Acquired Third Nerve Palsy Using a Population-Based Method.

          Among cranial nerve palsies, a third nerve palsy is important because a subset is caused by life-threatening aneurysms. However, there is significant disagreement regarding its incidence and the reported etiologies.
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            Typical features of cerebellar ataxic gait.

            Although gait disturbance is one of the most pronounced and disabling symptoms in cerebellar disease (CD), quantitative studies on this topic are rare. To characterise the typical clinical features of cerebellar gait and to analyse ataxia quantitatively. Twelve patients with various cerebellar disorders were compared with 12 age matched controls. Gait was analysed on a motor driven treadmill using a three dimensional system. A tandem gait paradigm was used to quantify gait ataxia. For normal locomotion, a significantly reduced step frequency with a prolonged stance and double limb support duration was found in patients with CD. All gait measurements were highly variable in CD. Most importantly, balance related gait variables such as step width and foot rotation angles were increased in CD, indicating the need for stability during locomotion. The tandem gait paradigm showed typical features of cerebellar ataxia such as dysmetria, hypometria, hypermetria, and inappropriate timing of foot placement. Typical features of gait in CD are reduced cadence with increased balance related variables and an almost normal range of motion (with increased variability) in the joints of the lower extremity. The tandem gait paradigm accentuates all the features of gait ataxia and is the most sensitive clinical test.
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              A review of the management of posterior communicating artery aneurysms in the modern era

              Background: Technical advancements have significantly improved surgical and endovascular treatment of cerebral aneurysms. In this paper, we review the literature with regard to treatment of one of the most common intra-cranial aneurysms encountered by neurosurgeons and interventional radiologists. Conclusions: Anterior clinoidectomy, temporary clipping, adenosine-induced cardiac arrest, and intraoperative angiography are useful adjuncts during surgical clipping of these aneurysms. Coil embolization is also an effective treatment alternative particularly in the elderly population. However, coiled posterior communicating artery aneurysms have a particularly high risk of recurrence and must be followed closely. Posterior communicating artery aneurysms with an elongated fundus, true posterior communicating artery aneurysms, and aneurysms associated with a fetal posterior communicating artery may have better outcome with surgical clipping in terms of completeness of occlusion and preservation of the posterior communicating artery. However, as endovascular technology improves, endovascular treatment of posterior communicating artery aneurysms may become equivalent or preferable in the near future. One in five patients with a posterior communicating artery aneurysm present with occulomotor nerve palsy with or without subarachnoid hemorrhage. Factors associated with a higher likelihood of recovery include time to treatment, partial third nerve deficit, and presence of subarachnoid hemorrhage. Both surgical and endovascular therapy offer a reasonable chance of recovery. Based on level 2 evidence, clipping appears to offer a higher chance of occulomotor nerve palsy recovery; however, coiling will remain as an option particularly in elderly patients or patients with significant comorbidity.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                24 November 2024
                November 2024
                : 16
                : 11
                : e74346
                Affiliations
                [1 ] Neurology, University of California (UC) Davis Medical Center, Sacramento, USA
                [2 ] Clinical Sciences, California Northstate University College of Medicine, Elk Grove, USA
                Author notes
                Article
                10.7759/cureus.74346
                11668228
                39720363
                c37b868b-2bed-4da9-bcea-cd94b36ad464
                Copyright © 2024, Zanella et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 November 2024
                Categories
                Neurology
                Internal Medicine
                Ophthalmology

                diabetes mellitus,neurology,neuro-ophthalmology,physical exam,stroke,third nerve palsy

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