Session: Free papers Session VIII - Graves & Neurologic disease

Update on third nerve palsy with cyclic spasm

Introduction

Cyclic spasm is peculiar and rare in third nerve palsies. It can combine different clinical features depending on the muscles that are involved. The main characteristics have been already described in the literature. We found new clinical features that seem not to have been described previously.

 

Material and Method

We studied a serial of 5 cases : 3 were congenital or early onset cases in children, 1 was acquired in a 40-year-old woman after stroke, 1 was acquired bilateral third nerve palsy after head trauma in a girl with cyclic spasm on the right eye and synkinesis on the left eye. We also studied a few more cases where transient cyclic spasm was suspected.as even though no spasm could be seen during office examination but as parents could show pictures with disappearance of the ptosis.

 

Results

Most of the clinical features were consistent with those described in the main review of literature by Clarke and Scott in 1975. In particular we had a case involving the lid, heralded by lid twitching. We also had a case involving the pupil. In another case, twitching of the lid was not followed by opening of the lid, and was considered as an aborted spasm. The two acquired cases were unusual as the spasms occurred in an aperiodic basis and were triggered either by pressing the inferior lid or by forced blinking, as if increasing pressure in the orbit could stimulate the levator. In one case, contrary to the rule, the spasm did not disappear under general anesthesia but disappeared during sleep.

 

Conclusion

Our study confirms that there are two main types of third nerve palsy with cyclic spasm, as described previously. However, spasms can occur in several other ways and can be aborted before the lid can fully elevate. It can be triggered by increasing pressure in the orbit. It can persist under general anesthesia. Cases of transient spasms without periodicity are probably underestimated and can be suspected on photographs or testimonies of the parents.