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Yang, Kim, and Hwang: Suprasellar Cysticercosis Associated With Partial Third Cranial Nerve Palsy Relieved by Surgical Cyst Removal
Case Report
Journal of the Korean Ophthalmological Society

Journal of the Korean Ophthalmological Society 2009; 50(4): 640-644.

Published online: 17 April 2009

DOI: https://doi.org/10.3341/jkos.2009.50.4.640

Suprasellar Cysticercosis Associated With Partial Third Cranial Nerve Palsy Relieved by Surgical Cyst Removal

Hee Kyung Yang, MD1, Chae-Yong Kim, MD2, Jeong-Min Hwang, MD1

1Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.

2Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.

Address reprint requests to Jeong-Min Hwang, MD. Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam 463-707, Korea. Tel: 82-31-787-7379, Fax: 82-31-787-4057, hjm@snu.ac.kr

Received 14 July 2008       Accepted 9 December 2008

Copyright © 2009 The Korean Ophthalmological Society

Abstract

Purpose

To report a case of partial third cranial nerve palsy in a patient with suprasellar cysticercosis. Surgical removal of the cyst was followed by symptom improvement.

Case summary

A 36-year-old man presented with binocular diplopia for 3 months. His best corrected visual acuities were 20/20 in both eyes, and both slit lamp and fundus examinations were unremarkable. The alternate prism cover test revealed four prism diopters (Δ) of exotropia and 4Δ of left hypotropia. Supraduction and adduction was mildly limited in the left eye. Pupil size was larger in the left eye and anisocoria was greater under bright light. Color test and visual field examination were normal. Neurologic examination showed a weakness of grade IV in the upper and lower extremities. Brain magnetic resonance imaging revealed a well-encapsulated cystic mass of homogeneous low intensity signal in the suprasellar area extending into the midbrain. Craniotomy and cyst removal were performed, and histologic findings were compatible with neurocysticercosis. Two weeks postoperatively the patient was free of diplopia and limb weakness.

Conclusions

Neurocysticercosis of a suprasellar origin may produce mass effects on the midbrain, inducing focal neurologic deficits of partial third cranial nerve palsy along with limb weakness. Masses of suprasellar origin can be successfully treated by surgical removal of the cyst.

Keywords: Cysticercosis, Diplopia, Suprasella, Surgical treatment, Third cranial nerve palsy

Figures and Tables

Figure 1
Nine gaze photograph of the patient reveals a marginal limitation of elevation of the left eye.
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Figure 2
Lancaster red-green test at the first visit revealed a small angle of left hypotropia and exotropia. The solid line represents the view of the left eye and the dotted line represents the view of the right eye. The left hypotropia increased in upgaze and right gaze. The angle of deviation increased with the left eye fixating (secondary deviation).
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Figure 3
(A) Preoperative T1-weighted axial magnetic resonance image showing a large cystic mass with homogeneous low signal intensity and well-defined borders (indicated by the white arrow), producing a mass effect in the midbrain mainly to the left, within the level of cerebral peduncles and fascicles of the oculomotor nerve in the brainstem. The head and neck of the larvae (scolex) is seen just next to the main mass (indicated by the hollow arrow). (B) Preoperative T1-weighted sagittal magnetic resonance image showing a homogeneous low signal intensity mass with well-defined borders compressing the midbrain and cerebral peduncles. (C) Postoperative gadolinium enhanced T1-weighted axial magnetic resonance image showing complete removal of the large cystic mass and an intact midbrain. There is a focal enhancing lesion just right to the interpeduncular cistern (indicated by the white arrow), most likely to be a post-operative reactive enhancement.
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Figure 4
Lancaster red-green test taken 2 weeks after cyst removal. The solid line represents the view of the left eye and the dotted line represents the view of the right eye. The angle of deviation has much decreased with minimal or no hypotropia or exotropia.
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