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Target exams

Red flags

• A painful third nerve palsy with pupillary involvement is a posterior communicating artery aneurysm until proven otherwise — a neurosurgical emergency requiring urgent CT angiography
• A pupil-involving complete third nerve palsy (down-and-out eye, ptosis, fixed dilated pupil) is compressive until excluded by vascular imaging
• Bilateral sixth nerve palsies with a headache and papilloedema signify raised intracranial pressure — the false-localising sign of a distant mass
• Acute bilateral facial weakness is rarely Bell palsy — think Guillain-Barre syndrome, Lyme disease, sarcoidosis and bilateral Bell palsy, and assess for ascending weakness and respiratory compromise
• A new partial third nerve palsy where the pupil is involved but the eye is not fully down-and-out can still be an expanding aneurysm — partial and pupil-involving lesions demand urgent imaging, never watchful waiting