Third nerve palsy as sole initial manifestation of GCA

This small retrospective study found that giant cell arteritis (GCA) can sometimes present with acute painful third nerve palsy, mimicking the presentation of a microvascular cause. Third nerve palsy often improves rapidly after initiation of steroid treatment.

The authors describe the presentation and course of four patients (aged 63 to 82) with third nerve palsy as the sole initial ocular manifestation of GCA.

One of the patients had a complete pupil-involving third nerve palsy, whereas the other three had pupils of equal size. Three of the patients reported severe ipsilateral periorbital and brow pain that began concomitantly with ocular symptoms up to three days prior.

Two patients reported no systemic symptoms of GCA but had elevated inflammatory markers. One had normal inflammatory markers but reported systemic symptoms of giant cell arteritis.

After initiation of high-dose oral prednisone, all patients had rapid improvement in symptoms and signs with all showing complete recovery within weeks.

The authors conclude that the presence of GCA symptoms or elevated inflammatory markers in a patient older than 50 with an acute third nerve palsy should prompt initiation of high-dose steroid treatment and temporal artery biopsy.