Pathology of the Ocular Motor Nerves III, IV, and VI

      The ocular motor nerves supply motor fibers to the extraocular muscles of the globe and levator muscle of the eyelid and parasympathetic pupillomotor fibers to the ciliary ganglion. Lesions are classified according to the anatomic location at which they occur: nuclear, fascicular, cisternal, cavernous, or orbital apex. The course each nerve follows influences the sites at which it is most vulnerable to damage and the pathologies to which it is exposed. Cranial nerve palsies frequently are associated with neurologic deficits that may assist in localizing the lesion anatomically. This article provides an overview of the pathology of the ocular motor nerves.

      Keywords

      To read this article in full you will need to make a payment
      Purchase one-time access
      Subscribers receive full online access to your subscription and archive of back issues up to and including 2002.
      Content published before 2002 is available via pay-per-view purchase only.
      Subscribe to Neuroimaging Clinics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rush J.A.
        • Younge B.R.
        Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases.
        Arch Ophthalmol. 1981; 99: 76-79
        • Richards B.W.
        • Jones F.R.
        • Younge B.R.
        Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves.
        Am J Ophthalmol. 1992; 113: 489-496
        • Bennett J.L.
        • Pelak V.S.
        Palsies of the third, fourth, and sixth cranial nerves.
        Ophthalmol Clin North Am. 2001; 14: 169-185
        • Yeh S.
        • Foroozan R.
        Orbital apex syndrome.
        Curr Opin Ophthalmol. 2004; 15: 490-498
        • Brazis P.W.
        Palsies of the trochlear nerve: diagnosis and localization—recent concepts.
        Mayo Clin Proc. 1993; 68: 501-509
        • Kim J.S.
        • Kim J.
        Pure midbrain infarction: clinical, radiologic, and pathophysiologic findings.
        Neurology. 2005; 64: 1227-1232
        • Blake P.Y.
        • Mark A.S.
        • Kattah J.
        • et al.
        MR of Oculomotor nerve palsy.
        AJNR Am J Neuroradiol. 1995; 16: 1665-1672
        • Kissel J.T.
        • Burde R.M.
        • Klingele T.G.
        • et al.
        Pupil-sparing oculomotor palsies with internal carotid-posterior communicating artery aneurysms.
        Ann Neurol. 1983; 13: 149-154
        • Mark A.S.
        • Blake P.
        • Atlas S.W.
        • et al.
        Gd-DTPA enhancement of the cisternal portion of the oculomotor nerve on MR imaging.
        AJNR Am J Neuroradiol. 1992; 13: 1463-1470
        • Hosoya T.
        • Adachi M.
        • Yamaguchi K.
        • et al.
        Abducens nerve enhancement demonstrated by multiplanar reconstruction of contrast-enhanced three-dimensional MRI.
        Neuroradiology. 2001; 43: 295-301
        • Jacobson D.M.
        • Trobe J.D.
        The emerging role of magnetic resonance angiography in the management of patients with third cranial nerve palsy.
        Am J Ophthalmol. 1999; 128: 94-96
        • Zhu Y.
        • Thulborn K.
        • Curnyn K.
        • et al.
        Sixth cranial nerve palsy caused by compression from a dolichoectatic vertebral artery.
        J Neuroophthalmol. 2005; 25: 134-135
        • Karamessini M.T.
        • Kagadis G.C.
        • Petsas T.
        • et al.
        CT angiography with three-dimensional techniques for the early diagnosis of intracranial aneurysms. Comparison with intra-arterial DSA and the surgical findings.
        Eur J Radiol. 2004; 49: 212-223
        • Kupersmith M.J.
        • Heller G.
        • Cox T.A.
        Magnetic resonance angiography and clinical evaluation of third nerve palsies and posterior communicating artery aneurysms.
        J Neurosurg. 2006; 105: 228-234
        • Lang J.
        Ueber Bau, Laenge und Gefaessbeziehungen der zentralen und peripheren Strecken der intrazisternalen Hirnnerven.
        Zentralbl Neurochir. 1982; 43 ([in German]): 217-255
        • Møller A.R.
        The cranial nerve vascular compression syndrome. I. A review of treatment.
        Acta Neurochir. 1991; 113: 18-23
        • Albayram S.
        • Ozer H.
        • Sarici A.
        • et al.
        Unilateral mydriasis without ophthalmoplegia—a sign of neurovascular compression? Case report.
        Neurosurgery. 2006; 58: 582-583
        • Marinkovic S.
        • Gibo H.
        • Zelic O.
        • et al.
        The neurovascular relationships and the blood supply of the trochlear nerve: surgical anatomy of its cisternal segment.
        Neurosurgery. 1996; 38: 161-169
        • Leigh R.J.
        • Tomask R.L.
        • Seidmann S.H.
        • et al.
        Superior oblique myokymia.
        Arch Ophthalmol. 1991; 109: 1710-1713
        • Marinkovic S.V.
        • Gibo H.
        • Stimec B.
        The neurovascular relationships and the blood supply of the abducent nerve: surgical anatomy of its cisternal segment.
        Neurosurgery. 1994; 34: 1017-1026
        • Yousry I.
        • Camelio S.
        • Wiesmann M.
        • et al.
        Detailed magnetic resonance imaging anatomy of the cisternal segment of the abducent nerve: Dorello's canal and neurovascular relationship and landmarks.
        J Neurosurg. 1999; 91: 276-283
        • Narai H.
        • Manabe Y.
        • Deguchi K.
        • et al.
        Isolated abducens nerve palsy caused by vascular compression.
        Neurology. 2000; 55: 453-454
        • Yousry I.
        • Moriggl B.
        • Dieterich M.
        • et al.
        MR anatomy of the proximal cisternal segment of the trochlear nerve: neurovascular relationships and landmarks.
        Radiology. 2002; 223: 31-37
        • Casselman J.W.
        • Dehaene I.
        Imaging of the IIIrd, IVth, and VIth cranial nerves.
        Neuroophthalmology. 1998; 19: 63-68
        • Yousry I.
        • Dieterich M.
        • Naidich T.P.
        • et al.
        Superior oblique myokymia: magnetic resonance imaging support for neurovascular compression hypothesis.
        Ann Neurol. 2002; 51: 361-368
        • Yousry I.
        • Moriggl B.
        • Schmid U.
        • et al.
        Detailed MR anatomy of the motor and sensory roots of the trigeminal nerve and their neurovascular relationships.
        J Neurosurg. 2004; 101: 427-434
        • Field M.
        • Jungreis C.A.
        • Chengelis N.
        • et al.
        Symptomatic cavernous sinus aneurysms: management and outcome after carotid occlusion and selective cerebral revascularization.
        AJNR Am J Neuroradiol. 2003; 24: 1200-1207
        • Larson T.L.
        Petrous apex and cavernous sinus: anatomy and pathology.
        Semin Ultrasound CT MR. 1993; 14: 232-246
        • Wu H.C.
        • Ro L.S.
        • Chen C.J.
        • et al.
        Isolated ocular motor nerve palsy in dural carotid-cavernous sinus fistula.
        Eur J Neurol. 2006; 13: 1221-1225
        • Mariak Z.
        • Mariak Z.
        • Stankiewicz A.
        Cranial nerve II-VII injuries in fatal closed head trauma.
        Eur J Ophthalmol. 1997; 7: 68-72
        • Muthu P.
        • Pritty P.
        Mild head injury with isolated third nerve palsy.
        Emerg Med J. 2001; 18: 310-311
        • Gentry L.R.
        Head trauma.
        in: Atlas S.W. Magnetic resonance imaging of the brain and spine. 3rd edition. Lippincott, Williams and Wilkins, Philadelphia2002: 1059-1098
        • Makki A.A.
        • Newman N.J.
        A trochlear stroke.
        Neurology. 2005; 65: 1989
        • Heinz J.
        Cranial nerve avulsion and other neural injuries.
        Med J Aust. 1969; 2: 1246-1249
        • Hanson R.A.
        • Ghosh S.
        • Gonzalez-Gomez I.
        • et al.
        Abducens length and vulnerability?.
        Neurology. 2004; 62: 33-36
        • Hara N.
        • Kan S.
        • Simizu K.
        Localization of post-traumatic trochlear nerve palsy associated with hemorrhage at the subarachnoid space by magnetic resonance imaging.
        Am J Ophthalmol. 2001; 132: 443-445
        • Sam B.
        • Ozveren M.F.
        • Akdemir I.
        • et al.
        The mechanism of injury of the abducens nerve in severe head trauma: a postmortem study.
        Forensic Sci Int. 2004; 140: 25-32
        • Keane J.R.
        Fourth nerve palsy: historical review and study of 215 inpatients.
        Neurology. 1993; 43: 2439-2443
        • Balcer L.J.
        • Galetta S.L.
        • Bagley L.J.
        • et al.
        Localization of traumatic oculomotor nerve palsy to the midbrain exit site by magnetic resonance imaging.
        Am J Ophthalmol. 1996; 122: 437-439
        • Bater M.C.
        • Ramchandani P.L.
        • Ramchandani M.
        • et al.
        An orbital apex fracture resulting in multiple cranial neuropathies.
        Br J Oral Maxillofac Surg. 2007; ([Epub ahead of print])
        • Mielke C.
        • Alexander M.S.
        • Anand N.
        Isolated bilateral trochlear nerve palsy as the first clinical sign of a metastatic [correction of metastasic] bronchial carcinoma.
        Am J Ophthalmol. 2001; 132: 593-594
        • Modi M.
        • Singla V.
        • Bhatia R.
        • et al.
        Isolated nuclear oculomotor nerve palsy due to a solitary midbrain metastasis: a rare presentation.
        Indian J Ophthalmol. 2006; 54: 286-287
        • Krohel G.B.
        • Mansour A.M.
        • Petersen W.L.
        • et al.
        Isolated trochlear nerve palsy secondary to a juvenile pilocytic astrocytoma.
        J Clin Neuroophthalmol. 1982; 2: 119-123
        • Leibovitch I.
        • Pakrou D.
        • Selva D.
        • et al.
        Neuro-ophthalmic manifestations of intracranial cavernous hemangiomas.
        Eur J Ophthalmol. 2006; 16: 148-152
        • Russell D.S.
        • Rubinstein L.J.
        Tumours of the cranial, spinal and peripheral nerve sheaths.
        in: Russell D.S. Rubinstein J. Pathology of tumors of the nervous system. 5th edition. Edward Arnold, London1989: 533-589
        • Ohba S.
        • Miwa T.
        • Kawase T.
        Trochlear nerve schwannoma with intratumoral hemorrhage: case report.
        Neurosurgery. 2006; 58: 791
        • Gentry L.R.
        • Mehta R.C.
        • Appen R.E.
        • et al.
        MR imaging of primary trochlear nerve neoplasms.
        AJNR Am J Neuroradiol. 1991; 12: 707-713
        • Tanriover N.
        • Kemerdere R.
        • Kafadar A.M.
        • et al.
        Oculomotor nerve schwannoma located in the oculomotor cistern.
        Surg Neurol. 2007; 67: 83-88
        • Acharya R.
        • Husain S.
        • Chabra S.S.
        • et al.
        Sixth nerve schwannoma: a case report with literature review.
        Neurol Sci. 2003; 24: 74-79
        • Celli P.
        • Ferrante L.
        • Acqui M.
        • et al.
        Neurinoma of the third, fourth, and sixth cranial nerves: a survey and report of a new fourth nerve case.
        Surg Neurol. 1992; 38: 216-224
        • Ho S.Y.
        • Kveton J.F.
        Acoustic neuroma. Assessment and management.
        Otolaryngol Clin North Am. 2002; 35: 393-404
        • Borges A.
        • Casselman J.
        Imaging the cranial nerves: part II: primary and secondary neoplastic conditions and neurovascular conflicts.
        Eur Radiol. 2007; 17: 2332-2344
        • Ginsberg F.
        • Peyster R.G.
        • Rose W.S.
        • et al.
        Sixth nerve schwannoma: MR and CT demonstration.
        J Comput Assist Tomogr. 1988; 12: 482-484
        • Wang Y.
        • Xiao L.H.
        Orbital schwannomas: findings from magnetic resonance imaging in 62 cases.
        Eye. 2007; ([Epub ahead of print])
        • Shen W.C.
        • Yang D.Y.
        • Ho W.L.
        • et al.
        Neurilemmoma of the oculomotor nerve presenting as an orbital mass: MR findings.
        AJNR Am J Neuroradiol. 1993; 14: 1253-1254
        • Deshmukh V.R.
        • Albuquerque F.C.
        • Zabramski J.M.
        • et al.
        Surgical management of cavernous malformations involving the cranial nerves.
        Neurosurgery. 2003; 53: 352-357
        • Kawamoto S.
        • Matsuda H.
        • Ueki K.
        • et al.
        Neuromuscular choristoma of the oculomotor nerve: case report.
        Neurosurgery. 2007; 60: 777-778
        • Eisenkraft B.
        • Ortiz A.O.
        Imaging evaluation of cranial nerves 3, 4, and 6.
        Semin Ultrasound CT MR. 2001; 22: 488-501
        • Harada T.
        • Ohashi T.
        • Ohki K.
        • et al.
        Clival chordoma presenting as acute esotropia due to bilateral abducens palsy.
        Ophthalmologica. 1997; 211: 109-111
        • Gay E.
        • Sekhar L.N.
        • Rubinstein E.
        • et al.
        Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients.
        Neurosurgery. 1995; 36: 887-896
        • Barkovich A.J.
        Intracranial, orbital and neck masses of childhood.
        in: Barkovich A.J. Pediatric neuroimaging. 4th edition. Lippincott, Williams and Wilkins, Philadelphia2005: 506-658
        • Saremi F.
        • Helmy M.
        • Farzin S.
        • et al.
        MRI of cranial nerve enhancement.
        AJR Am J Roentgenol. 2005; 185: 1487-1497
        • Petermann S.H.
        • Newman N.J.
        Pituitary macroadenoma manifesting as an isolated fourth nerve palsy.
        Am J Ophthalmol. 1999; 127: 235-236
        • Knosp E.
        • Steiner E.
        • Kitz K.
        • et al.
        Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings.
        Neurosurgery. 1993; 33: 610-617
        • Cottier J.-P.
        • Destrieux C.
        • Brunereau L.
        • et al.
        Cavernous sinus invasion by pituitary adenoma: MR imaging.
        Radiology. 2000; 215: 463-469
        • Riedl M.
        • Clodi M.
        • Kotzmann H.
        • et al.
        Apoplexy of a pituitary macroadenoma with reversible third, fourth and sixth cranial nerve palsies following administration of hypothalamic releasing hormones: MR features.
        Eur J Radiol. 2000; 36: 1-4
        • Bills D.C.
        • Meyer F.B.
        • Laws Jr., E.R.
        • et al.
        A retrospective analysis of pituitary apoplexy.
        Neurosurgery. 1993; 33: 602-609
        • Chen Z.
        • Murray A.W.
        • Quinlan J.J.
        Pituitary apoplexy presenting as unilateral third cranial nerve palsy after coronary artery bypass surgery.
        Anesth Analg. 2004; 98: 46-48
        • Rossitch Jr., E.
        • Carrazana E.J.
        • Black P.M.
        Isolated oculomotor nerve palsy following apoplexy of a pituitary adenoma.
        J Neurosurg Sci. 1992; 36: 103-105
        • Nakagawa T.
        • Uchida K.
        • Ozveren M.F.
        • et al.
        Abducens schwannoma inside the cavernous sinus proper: case report.
        Surg Neurol. 2004; 61: 559-563
        • Shi J.
        • Hang C.
        • Pan Y.
        • et al.
        Cavernous hemangiomas in the cavernous sinus.
        Neurosurgery. 1999; 45: 1308-1313
        • Sohn C.H.
        • Kim S.P.
        • Kim I.M.
        • et al.
        Characteristic MR imaging findings of cavernous hemangiomas in the cavernous sinus.
        AJNR Am J Neuroradiol. 2003; 24: 1148-1151
        • Srinivasan S.
        • Fern A.I.
        • Wilson K.
        Orbital apex syndrome as a presenting sign of maxillary sinus carcinoma.
        Eye. 2001; 15: 343-345
        • Gore H.L.
        • Corin S.M.
        • Klussmann K.G.
        • et al.
        Mucoepidermoid carcinoma presenting as an orbital apex syndrome.
        Ophthalmic Surg. 1992; 23: 59-61
        • McDonald H.R.
        • Char D.H.
        Adenoid cystic carcinoma presenting as an orbital apex syndrome.
        Ann Ophthalmol. 1985; 17: 757-759
        • Parker G.D.
        • Harnsberger H.R.
        Clinical-radiologic issues in perineural tumor spread of malignant diseases of the extracranial head and neck.
        Radiographics. 1991; 11: 383-399
        • Chang P.C.
        • Fischbein N.J.
        • McCalmont T.H.
        • et al.
        Perineural spread of malignant melanoma of the head and neck: clinical and imaging features.
        AJNR Am J Neuroradiol. 2004; 25: 5-11
        • Veness M.J.
        • Biankin S.
        Perineural spread leading to orbital invasion from skin cancer.
        Australas Radiol. 2000; 44: 296-302
        • de Seze J.
        • Vukusic S.
        • Viallet-Marcel M.
        • et al.
        Unusual ocular motor findings in multiple sclerosis.
        J Neurol Sci. 2006; 243: 91-95
        • Thomke F.
        • Ringel K.
        Isolated superior oblique palsies with brainstem lesions.
        Neurology. 1999; 53: 1126-1127
        • Lee S.H.
        • Yoon P.H.
        • Park S.J.
        • et al.
        MRI findings in neuro-Behçet's disease.
        Clin Radiol. 2001; 56: 485-494
        • Aydin M.D.
        • Aydin N.
        A neuro-Behcet's lesion in oculomotor nerve nucleus.
        Acta Neurol Scand. 2003; 108: 139-141
        • Coban O.
        • Bahar S.
        • Akman-Demir G.
        • et al.
        Masked assessment of MRI findings: is it possible to differentiate neuro-Behcet's disease from other central nervous system diseases?.
        Neuroradiology. 1999; 41: 255-260
        • Borges A.
        • Casselman J.
        Imaging the cranial nerves: part I: methodology, infectious and inflammatory, traumatic and congenital lesions.
        Eur Radiol. 2007; 17: 2112-2125
        • Garcia-Rivera C.A.
        • Rozen T.D.
        • Zhou D.
        • et al.
        Miller Fisher syndrome: MRI findings.
        Neurology. 2001; 57: 1755
        • Nagaoka U.
        • Kato T.
        • Kurita K.
        • et al.
        Cranial nerve enhancement on three-dimensional MRI in Miller Fisher syndrome.
        Neurology. 1996; 47: 1601-1602
        • Crevits L.
        • Verschelde H.
        • Casselman J.
        Ophthalmoplegic migraine: an unresolved problem.
        Cephalalgia. 2006; 26: 1255-1259
        • Mark A.S.
        • Casselman J.
        • Brown D.
        • et al.
        Ophthalmoplegic migraine: reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrast-enhanced MR images.
        AJNR Am J Neuroradiol. 1998; 19: 1887-1891
        • Celebisoy N.
        • Sirin H.
        • Gokcay F.
        Ophthalmoplegic migraine: two patients, one at middle age with abducens palsy.
        Cephalalgia. 2005; 25: 151-153
        • La Mantia L.
        • Curone M.
        • Rapoport A.M.
        • et al.
        International Headache Society. Tolosa-Hunt syndrome: critical literature review based on IHS 2004 criteria.
        Cephalalgia. 2006; 26: 772-781
        • de Arcaya A.A.
        • Cerezal L.
        • Canga A.
        • et al.
        Neuroimaging diagnosis of Tolosa-Hunt syndrome: MRI contribution.
        Headache. 1999; 39: 321-325
        • Wasenko J.J.
        • Park B.J.
        • Jubelt B.
        • et al.
        Magnetic resonance imaging of mesenrhombencephalitis.
        Clin Imaging. 2002; 26: 237-242
        • Im M.
        • Kim B.J.
        • Seo Y.J.
        • et al.
        Complete ophthalmoplegia after herpes zoster.
        Clin Exp Dermatol. 2007; 32: 162-164
        • Quisling S.V.
        • Shah V.A.
        • Lee H.K.
        • et al.
        Magnetic resonance imaging of third cranial nerve palsy and trigeminal sensory loss caused by herpes zoster.
        J Neuroophthalmol. 2006; 26: 47-48
        • Lell M.
        • Schmid A.
        • Stemper B.
        • et al.
        Simultaneous involvement of third and sixth cranial nerve in a patient with Lyme disease.
        Neuroradiology. 2003; 45: 85-87
        • Savas R.
        • Sommer A.
        • Gueckel F.
        • et al.
        Isolated oculomotor nerve paralysis in Lyme disease: MRI.
        Neuroradiology. 1997; 39: 139-141
        • Sherman S.C.
        • Buchanan A.
        Gradenigo syndrome: a case report and review of a rare complication of otitis media.
        J Emerg Med. 2004; 27: 253-256
        • Siddiqui A.A.
        • Bashir S.H.
        • Ali Shah A.
        • et al.
        Diagnostic MR imaging features of craniocerebral Aspergillosis of sino-nasal origin in immunocompetent patients.
        Acta Neurochir (Wien). 2006; 148: 155-166