Disclosures: Du Pham, MD: Nothing to disclose

Case Description: A 43-year-old woman presented to the emergency department unresponsive. Initial exam included bilateral fixed, dilated, nonreactive pupils. Computed tomography (CT) head revealed extensive bilateral infarcts in posterior circulation territories. CT angiography revealed occlusion of basilar artery with filling defects in branches leading to bilateral posterior cerebral arteries. Patient was revascularized, stabilized, then admitted to inpatient rehabilitation unit. Deficits on admittance included ataxic quadriparesis, cognitive deficits, bilateral ptosis/apraxia of eyelid opening, pupil nonreactivity, and ocular movement deficits consistent with combined cranial nerve (CN) III and CN IV palsies. Patient spent 3 weeks in intensive therapy, with marked improvements in motor, speech, and independence. However, all of her ocular deficits remained.

Setting: Inpatient Rehab

Patient: 43-year-old woman with combined CN III & IV palsies.

Assessment/Results: NA

Discussion: Ocular movement abnormality is a common symptom affecting over half of all stroke patients. However, only a small percentage is from damage to bilateral cranial nerves, leading to a scarcity of available data on prognosis and management. Recovery from unilateral ocular CN palsies typically takes from several weeks to 6 months, with non-traumatic cases carrying a more favorable prognosis. However, previous studies on non-traumatic cases mostly looked at non-stroke causes (diabetes, tumors, aneurysms). Treatment aims to control symptoms of diplopia and strabismus, and involves prisms, eye patches, compensatory posturing, visual scanning strategies, botulinum injections in antagonistic eye muscles, or surgery to correct misalignment if problems persist for more than 6 months. Prognosis tends to be poor when there is concurrent infarcts of other regions. Our patient’s ocular symptoms persist for at least 2 months after stroke, hinting at a more unfavorable course that might require surgical correction in the future.

Conclusion: Bilateral combined CN palsies remain a challenge for clinicians in rehab. Due to limited data, treatment and prognosis are not well understood, and thus should warrant continued investigation.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-case-of-bilateral-combined-cranial-nerve-iii-iv-palsies-after-stroke/