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A retrospective chart review is presented with the aim of evaluating arterial imaging in cases of third nerve palsy. The study reviewed patients seen with a suspicion of or a final diagnosis of third nerve palsy over a seven-year eight-month period at two centres. Exclusion criteria included being under 18 years of age, minimal information on referral letter and non-isolated third nerve palsy. One hundred and ten patients were included in the analysis. Diplopia and ptosis were the most common presenting complaints. A quarter of care providers failed to record one element crucial for diagnosis of third nerve palsy – ocular motility, ptosis or pupils. The authors report that 36% of all cases and 40% of cases with a referral due to suspicion of third nerve palsy had urgent arterial imaging. The median delay reported between symptom onset and imaging was 24 days, and between first contact with healthcare professionals and imaging, 13 days. Harm was reported to have been experience by one patient. The authors conclude that the delays in obtaining arterial imaging in these patients was a result of not recognising that arterial imaging is required urgently when third nerve palsy is suspected in order to eliminate posterior communicating artery aneurysm as an aetiology. This study identified potential incomplete examinations, delays in referral to neuro-ophthalmology as well as the delays in imaging. Several limitations of the study are highlighted by the authors including the use of a single site, patient presentation with improving symptoms and exclusion criteria. This study highlights the potential need to make improvements to the care pathways for suspected third nerve palsy which could prevent lethal undiagnosed aneurysm rupture.

Failure to obtain urgent arterial imaging in acute third nerve palsies.
Chung JE, Schroeder RM, Wilson B, et al.
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Lauren R Hepworth

University of Liverpool; Honorary Stroke Specialist Clinical Orthoptist, Northern Care Alliance NHS Foundation Trust; St Helen’s and Knowsley NHS Foundation Trust, UK.

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