[2026-01-26] Bilateral Third Nerve Palsies Secondary to Pituitary Apoplexy: A Case Report

Abstract

Background: Bilateral third cranial nerve palsies resulting from pituitary apoplexy with bilateral lateral expansion compressing bilateral third cranial nerves at the cavernous sinuses walls are uncommon.

Case Presentation: A 31-year-old healthy male complained of an acute severe headache, bilateral ptosis, and binocular horizontal diplopia for about 4 days. Eye examinations revealed incomplete ptosis, partial limitation of supraduction, infraduction, complete limitation of adduction, and dilated pupils in both eyes associated with bitemporal hemianopia. A brain computerized tomography (CT) scan with contrast revealed an intra- and suprasellar pituitary mass. Brain magnetic resonance imaging (MRI) reported a heterogenous mass measuring 3.0 × 3.1 × 3.8 cm involving the sphenoid sinus, sella turcica, and suprasellar cistern. Hormonal workup revealed the first diagnosis of type 2 diabetes mellitus, hyperprolactinemia, central hypothyroidism, and hypogonadotropic hypogonadism. The patient received hormonal supplements and the tumor was successfully treated by endoscopic surgery. Pathological confirmation of pituitary hemorrhage was found. All ocular and neurological deficits were completely resolved within 6 months postsurgery. Follow-up MRIs at 3 months and 1 year showed no residual tumor; however, hypogonadotropic hypogonadism and postoperative diabetes insipidus persisted for 4 months.

Conclusions:  Localization of the third cranial nerve palsy was significant in determining the possibility of a lesion and detecting an emergency condition causing potential life-threatening complications. Most cases of third cranial nerve palsy from pituitary tumors effect one side, but this case is unusual because it involved both sides, showing a rare pattern of tumor growth and compression.