Referring Clinicians Lack Awareness of Third Nerve Palsy Imaging Urgency

Isolated third nerve palsies have various origins, which include expanding posterior communicating aneurysm (PCommaA), which can be identified using arterial imaging.

Researchers conducted a retrospective chart review of adult patients suspected of possible third nerve palsy and found that referring physicians may not recognize the urgency of arterial imaging in third nerve palsies. They presented their work at the North American Neuro-Ophthalmology Society 2021 Meeting.

The investigators sought to discover the rate, duration, and rationale of any such delays, and determine any resulting patient harm. 

They reviewed 110 cases of adult patients who attended a neuro-ophthalmology clinic and consultation service at a tertiary institution between November 2012 and June 2020.

The patients had a mean age of 61.8 years, were mostly women  (n=62), and mostly White (n=88). They had been referred by providers of several specialties, including 48 patients who were referred via ophthalmology and 19 patients who were referred via optometry. Five patients presented without referral.

Forty patients received urgent arterial imaging. Thirty-five patients who were referred for third nerve palsy received urgent arterial imaging (P =.082). Referring providers did not recognize third nerve palsy in 17 of the 95 patients who received that final diagnosis.

The researchers found no significant association between referral for third nerve palsy and urgent consultation (P =.29) or urgent arterial imaging (P =.082). They discovered a median 12.5 days and a mean 23 days (SD 31.7) passed between first medical contact and arterial imaging for patients who received the imaging only following neuro-ophthalmology consultation. The mean number of days between symptom onset and arterial imaging was 32 (SD 32.1), with a median of 24 days.

A delay in arterial imaging for 1 patient resulted in delayed detection of metastatic mass in the cavernous sinus, the study says.

“Patient care could be improved by raising awareness of the necessity for urgent arterial imaging in patients with acute-onset isolated third nerve palsies,” the study says.

Reference

Chung JE, Schroeder RM, Wilson B, Van Stavern GP, Stunkel L. Timeliness of arterial imaging in third nerve palsies. Presented at: North American Neuro-Ophthalmology Society Annual Meeting; February 20-23, 2021; Poster 82.