Reduced chemical and electrical connections of fast-spiking interneurons in experimental cortical dysplasia.

Aberrant neural connections are regarded as a principal factor contributing to epileptogenesis. This study examined chemical and electrical connections between fast-spiking (FS), parvalbumin (PV)-immunoreactive (FS-PV) interneurons and regular-spiking (RS) neurons (pyramidal neurons or spiny stellate neurons) in a rat model of prenatal irradiation-induced cortical dysplasia. Presynaptic action potentials were evoked by current injection and the elicited unitary inhibitory or excitatory postsynaptic potentials (uIPSPs or uEPSPs) were recorded in the postsynaptic cell. In dysplastic cortex, connection rates between presynaptic FS-PV interneurons and postsynaptic RS neurons and FS-PV interneurons, and uIPSP amplitudes were significantly smaller than controls, but both failure rates and coefficient of variation of uIPSP amplitudes were larger than controls. In contrast, connection rates from RS neurons to FS-PV interneurons and uEPSPs amplitude were similar in the two groups. Assessment of the paired pulse ratio showed a significant decrease in synaptic release probability at FS-PV interneuronal terminals, and the density of terminal boutons on axons of biocytin-filled FS-PV interneurons was also decreased, suggesting presynaptic dysfunction in chemical synapses formed by FS-PV interneurons. Electrical connections were observed between FS-PV interneurons, and the connection rates and coupling coefficients were smaller in dysplastic cortex than controls. In dysplastic cortex, we found a reduced synaptic efficiency for uIPSPs originating from FS-PV interneurons regardless of the type of target cell, and impaired electrical connections between FS-PV interneurons. This expands our understanding of the fundamental impairment of inhibition in this model and may have relevance for certain types of human cortical dysplasia.

TRPC3 mediates hyperexcitability and epileptiform activity in immature cortex and experimental cortical dysplasia.

Neuronal hyperexcitability plays an important role in epileptogenesis. Conditions of low extracellular calcium (Ca) or magnesium (Mg) can induce hyperexcitability and epileptiform activity with unclear mechanisms. Transient receptor potential canonical type 3 (TRPC3) channels play a pivotal role in neuronal excitability and are activated in low-Ca and/or low-Mg conditions to depolarize neurons. TRPC3 staining was highly enriched in immature, but very weak in mature, control cortex, whereas it was strong in dysplastic cortex at all ages. Depolarization and susceptibility to epileptiform activity increased with decreasing Ca and Mg. Combinations of low Ca and low Mg induced larger depolarization in pyramidal neurons and greater susceptibility to epileptiform activity in immature and dysplastic cortex than in mature and control cortex, respectively. Intracellular application of anti-TRPC3 antibody to block TRPC3 channels and bath application of the selective TRPC3 inhibitor Pyr3 greatly diminished depolarization in immature control and both immature and mature dysplastic cortex with strong TRPC3 expression. Epileptiform activity was initiated in low Ca and low Mg when synaptic activity was blocked, and Pyr3 completely suppressed this activity. In conclusion, TRPC3 primarily mediates low Ca- and low Mg-induced depolarization and epileptiform activity, and the enhanced expression of TRPC3 could make dysplastic and immature cortex more hyperexcitable and more susceptible to epileptiform activity.

Cavernoma-related epilepsy: review and recommendations for management--report of the Surgical Task Force of the ILAE Commission on Therapeutic Strategies.

Cerebral cavernous malformations (CCMs) are well-defined, mostly singular lesions present in 0.4-0.9% of the population. Epileptic seizures are the most frequent symptom in patients with CCMs and have a great impact on social function and quality of life. However, patients with CCM-related epilepsy (CRE) who undergo surgical resection achieve postoperative seizure freedom in only about 75% of cases. This is frequently because insufficient efforts are made to adequately define and resect the epileptogenic zone. The Surgical Task Force of the Commission on Therapeutics of the International League Against Epilepsy (ILAE) and invited experts reviewed the pertinent literature on CRE. Definitions of definitive and probable CRE are suggested, and recommendations regarding the diagnostic evaluation and etiology-specific management of patients with CRE are made. Prospective trials are needed to determine when and how surgery should be done and to define the relations of the hemosiderin rim to the epileptogenic zone.

Impaired hippocampal memory function and synaptic plasticity in experimental cortical dysplasia.

PURPOSE: Memory impairment is a common comorbidity in people with epilepsy-associated malformations of cortical development. We studied spatial memory performance and hippocampal synaptic plasticity in an animal model of cortical dysplasia. METHODS: Embryonic day 17 rats were exposed to 2.25 Gy external radiation. One-month-old rats were tested for spatial recognition memory. After behavioral testing, short-term and long-term synaptic plasticity in the hippocampal CA1 region was studied in an in vitro slice preparation. KEY FINDINGS: Behavioral assessments showed impaired hippocampal CA1-dependent spatial recognition memory in irradiated rats. Neurophysiologic assessments showed that baseline synaptic transmission was significantly enhanced, whereas paired-pulse facilitation, long-term potentiation, and long-term depression of the field excitatory postsynaptic potential (fEPSP) slope at Schaffer collateral/commissural fiber-CA1 synapses were significantly reduced in the irradiated rats. Histologic observations showed dysplastic cortex and dispersed hippocampal pyramidal neurons. SIGNIFICANCE: This study has shown that prenatally irradiated rats with cortical dysplasia exhibit a severe impairment of spatial recognition memory accompanied by disrupted short-term and long-term synaptic plasticity and may help to guide development of potential therapeutic interventions for this important problem.

Altered firing rates and patterns in interneurons in experimental cortical dysplasia.

Cortical dysplasia (CD) is associated with severe epilepsy in humans, and the in utero irradiation of fetal rats provides a model of this disorder. These animals show a selective loss of inhibitory interneurons, and the surviving interneurons have a reduced excitatory synaptic drive. The current study was undertaken to see how alterations in synaptic input would affect spontaneous firing of interneurons in dysplastic cortex. We recorded spontaneous action potentials and excitatory and inhibitory postsynaptic currents (EPSCs and IPSCs, respectively) from somatostatin (SST)-, parvalbumin (PV)-, and calretinin (CR)-immunoreactive (ir) interneurons. We found that SST- and PV-ir interneurons fired less frequently and with less regularity than controls. This corresponded to a relative imbalance in the ratio of EPSCs to IPSCs that favored inhibition. In contrast, CR-ir interneurons from CD showed no differences from controls in spontaneous firing or ratio of EPSCs to IPSCs. Additional studies demonstrated that synaptic input had a powerful effect on spontaneous firing in all interneurons. These findings demonstrate that a relative reduction in excitatory drive results in less active SST- and PV-ir interneurons in irradiated rats. This would further impair cortical inhibition in these animals and may be an important mechanism of epileptogenesis.

Altered behavior in experimental cortical dysplasia.

PURPOSE: Developmental delay and cognitive impairment are common comorbidities in people with epilepsy associated with malformations of cortical development (MCDs). We studied cognition and behavior in an animal model of diffuse cortical dysplasia (CD), in utero irradiation, using a battery of behavioral tests for neuromuscular and cognitive function. METHODS: Fetal rats were exposed to 2.25 Gy external radiation on embryonic day 17 (E17). At 1 month of age they were tested using an open field task, a grip strength task, a grid walk task, inhibitory avoidance, an object recognition task, and the Morris water maze task. KEY FINDINGS: Rats with CD showed reduced nonlocomotor activity in the open field task and impaired motor coordination for grid walking but normal grip strength. They showed a reduced tendency to recognize novel objects and reduced retention in an inhibitory avoidance task. Water maze testing showed that learning and memory were impaired in irradiated rats for both cue discrimination and spatially oriented tasks. These results demonstrate significant deficits in cortex- and hippocampus-dependent cognitive functions associated with the diffuse abnormalities of cortical and hippocampal development that have been documented in this model. SIGNIFICANCE: This study documents multimodal cognitive deficits associated with CD and can serve as the foundation for future investigations into the mechanisms of and possible therapeutic interventions for this problem.

Common data elements in epilepsy research: development and implementation of the NINDS epilepsy CDE project.

The Common Data Element (CDE) Project was initiated in 2006 by the National Institute of Neurological Disorders and Stroke (NINDS) to develop standards for performing funded neuroscience-related clinical research. CDEs are intended to standardize aspects of data collection; decrease study start-up time; and provide more complete, comprehensive, and equivalent data across studies within a particular disease area. Therefore, CDEs will simplify data sharing and data aggregation across NINDS-funded clinical research, and where appropriate, facilitate the development of evidenced-based guidelines and recommendations. Epilepsy-specific CDEs were established in nine content areas: (1) Antiepileptic Drugs (AEDs) and Other Antiepileptic Therapies (AETs), (2) Comorbidities, (3) Electrophysiology, (4) Imaging, (5) Neurological Exam, (6) Neuropsychology, (7) Quality of Life, (8) Seizures and Syndromes, and (9) Surgery and Pathology. CDEs were developed as a dynamic resource that will accommodate recommendations based on investigator use, new technologies, and research findings documenting emerging critical disease characteristics. The epilepsy-specific CDE initiative can be viewed as part of the larger international movement toward "harmonization" of clinical disease characterization and outcome assessment designed to promote communication and research efforts in epilepsy. It will also provide valuable guidance for CDE improvement during further development, refinement, and implementation. This article describes the NINDS CDE Initiative, the process used in developing Epilepsy CDEs, and the benefits of CDEs for the clinical investigator and NINDS.

The clinicopathologic spectrum of focal cortical dysplasias: a consensus classification proposed by an ad hoc Task Force of the ILAE Diagnostic Methods Commission.

PURPOSE: Focal cortical dysplasias (FCD) are localized regions of malformed cerebral cortex and are very frequently associated with epilepsy in both children and adults. A broad spectrum of histopathology has been included in the diagnosis of FCD. An ILAE task force proposes an international consensus classification system to better characterize specific clinicopathological FCD entities. METHODS: Thirty-two Task Force members have reevaluated available data on electroclinical presentation, imaging, neuropathological examination of surgical specimens as well as postsurgical outcome. KEY FINDINGS: The ILAE Task Force proposes a three-tiered classification system. FCD Type I refers to isolated lesions, which present either as radial (FCD Type Ia) or tangential (FCD Type Ib) dyslamination of the neocortex, microscopically identified in one or multiple lobes. FCD Type II is an isolated lesion characterized by cortical dyslamination and dysmorphic neurons without (Type IIa) or with balloon cells (Type IIb). Hence, the major change since a prior classification represents the introduction of FCD Type III, which occurs in combination with hippocampal sclerosis (FCD Type IIIa), or with epilepsy-associated tumors (FCD Type IIIb). FCD Type IIIc is found adjacent to vascular malformations, whereas FCD Type IIId can be diagnosed in association with epileptogenic lesions acquired in early life (i.e., traumatic injury, ischemic injury or encephalitis). SIGNIFICANCE: This three-tiered classification system will be an important basis to evaluate imaging, electroclinical features, and postsurgical seizure control as well as to explore underlying molecular pathomechanisms in FCD.

Densities of glutamatergic and GABAergic presynaptic terminals are altered in experimental cortical dysplasia.

PURPOSE: Cortical dysplasia (CD) is a major cause of epilepsy in children and adults, but underlying mechanisms of epileptogenesis in this disorder are poorly understood. We have utilized the irradiated rat model to study an injury-based form of diffuse CD in rats. Prior studies in this model have shown reduced numbers of γ-aminobutyric acid (GABA)ergic interneurons and reduced inhibitory synaptic currents in pyramidal cells in CD. We analyzed the number of excitatory and inhibitory presynaptic terminals in the neocortex of irradiated rats to better characterize altered connectivity in experimental CD. METHODS: Antibodies to vesicular glutamate transporter 1 (VGLUT1), vesicular glutamate transporter 2 (VGLUT2), vesicular GABA transporter (VGAT), and parvalbumin (PV) were used to quantify glutamatergic and GABAergic presynaptic terminals in control and dysplastic cortex. RESULTS: We found that the density of VGLUT1 terminals was increased in CD in comparison to layers IV, V, and VI in control cortex. VGLUT2 terminals were increased in CD compared to layers IV and VI. VGAT terminals were reduced in CD compared to layers II/III, IV, and V in controls as were PV-immunoreactive somata and terminals. DISCUSSION: These findings suggest an overall increase in excitatory synaptic connectivity and decrease in inhibitory synaptic connectivity in CD in irradiated rat. We propose that these changes contribute to hyperexcitability in these animals and may contribute to epileptogenicity in some forms of human CD.

Disrupting abnormal electrical activity with deep brain stimulation: is epilepsy the next frontier?

Given the tremendous success of deep brain stimulation (DBS) for the treatment of movement and neuropsychiatric disorders, clinicians have begun to open up to the possible use of electrical stimulation for the treatment of patients with uncontrolled seizures. This process has resulted in the discovery of a wide array of DBS targets, including the cerebellum, hypothalamus, hippocampus, basal ganglia, and various thalamic nuclei. Despite the ambiguity of the mechanism of action and the unknowns surrounding potentially ideal stimulation settings, several recent trials have empirically demonstrated reasonable efficacy in selected cases of medication-refractory seizures. These exciting results have fueled a number of studies aimed at firmly establishing DBS as an effective treatment for selected cases of intractable epilepsy, and many companies are aiming at Food and Drug Administration approval. We endeavor to review the studies in the context of the various DBS targets and their relevant circuitry for epilepsy. Based on the unfolding research, DBS has the potential to play an important role in treating refractory epilepsy. The challenge, as in movement disorders, is to assemble interdisciplinary teams to screen, implant, and follow patients, and to clarify patient selection. The future will undoubtedly be filled with optimization of targets and stimulation parameters and the development of best practices. With tailored therapeutic approaches, epilepsy patients have the potential to improve with DBS.

Comparing Standard Performance and Outcome Measures in Hospitalized Pituitary Tumor Patients with Secretory versus Nonsecretory Tumors.

BACKGROUND: Patient safety indicators (PSIs) and hospital-acquired conditions (HACs) are reported quality measures. We compared their prevalence in patients with secretory and nonsecretory pituitary adenoma using the National (Nationwide) Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. METHODS: The NIS was queried for hospitalizations 2002-2014 involving pituitary adenomas. Prevalence of PSI, HAC, and 9 pituitary-related complications was determined using International Classification of Diseases, Ninth Revision codes. Patient risk factors were evaluated through multivariate analysis. RESULTS: A total of 20,743 patients with nonsecretory tumor and 3385 patients with secretory tumor were identified. Among patients with nonsecretory tumor, 3.79% experienced any PSI or HAC. Of patients with secretory tumor, 2.54% had any PSI or HAC. Before adjusting for covariation, secretory patients were less likely to have any PSI or HAC (odds ratio [OR], 0.652; P = 0.0002), experience any pituitary-related complication (OR, 0.804; P < 0.0001), have a poor outcome (hazard ratio [HR], 0.435; P < 0.0001), and die during hospitalization (HR, 0.293; P = 0.0015). Secretory patients had significantly shorter mean hospital length of stay (secretory/nonsecretory percent difference, -11.95%; P < 0.0001). However, inverse propensity score-weighted ORs comparing the groups' outcomes showed that there was no significant difference in the prevalence of any PSIs and HACs (OR, 0.963; P = 0.8570), pituitary-related complications (OR, 0.894; P = 0.1321), poor outcomes (HR, 0.990; P = 0.9287), in-hospital death (HR, 0.663; P = 0.2967), and length of stay (percent difference, -2.31%; P = 0.2967) between groups. CONCLUSIONS: Lack of significant difference in outcome measures after controlling for covariation is consistent with our finding that patients with nonsecretory tumor have more comorbidities on presentation for treatment. PSIs and HACs have limited ability to measure complications specific to pituitary tumors.

Balance of inhibitory and excitatory synaptic activity is altered in fast-spiking interneurons in experimental cortical dysplasia.

Cortical dysplasia (CD) is a common cause of intractable epilepsy in children and adults. We have studied rats irradiated in utero as a model of CD to better understand mechanisms that underlie dysplasia-associated epilepsy. Prior studies have shown a reduction in the number of cortical interneurons and in the frequency of inhibitory postsynaptic currents (IPSCs) in pyramidal cells in this model. They have also shown a reduced frequency of spontaneous and miniature excitatory postsynaptic currents (EPSCs) in the surviving cortical interneurons. However, the inhibitory synaptic contacts were not examined in that study. The current experiments were performed to assess inhibitory synaptic activity in fast-spiking (FS) interneurons in irradiated rats and controls and the balance of excitatory and inhibitory synaptic activity in these cells. Whole cell recordings were obtained from layer IV FS cells in controls and comparable FS cells in irradiated rats. The frequency of spontaneous and miniature IPSCs was reduced in dysplastic cortex, but the amplitude of these currents was unchanged. Stimulus-evoked IPSCs showed short-term depression in control and short-term facilitation in dysplastic cortex. Simultaneous recording of spontaneous EPSCs and IPSCs showed a shift in the ratio of excitation-to-inhibition in favor of inhibition in FS cells from dysplastic cortex. The same shift toward inhibition was seen when miniature EPSCs and IPSCs were examined. These results show that FS cells in dysplastic cortex have a relative lack of excitatory drive. This may result in an important class of inhibitory cells that are less able to perform their normal function especially in periods of increased excitatory activity.

Long-term potentiation of excitatory synapses on neocortical somatostatin-expressing interneurons.

Synaptic plasticity has been extensively studied in principal neurons of the neocortex, but less work has been done on GABAergic interneurons. Interneurons consist of multiple subtypes and their synaptic properties vary between subtypes. In the present study, we have examined long-term potentiation (LTP) of excitatory synapses on somatostatin (SS)-expressing interneurons in neocortex using transgenic mice that express enhanced green fluorescent protein in these interneurons. We found that a strong theta burst stimulation was required to induce LTP in SS interneurons. LTP was associated with a reduction in paired-pulse facilitation and was not blocked by an N-methyl-d-aspartate receptor (NMDAR) antagonist. LTP was not affected by chelating postsynaptic Ca(2+) with BAPTA, a fast Ca(2+) chelator, and blocking L-type voltage-dependent Ca(2+) channels with nimodipine. Application of forskolin, an activator of adenylate cyclase that increases cyclic adenosine monophosphate (cAMP) concentration, enhanced synaptic transmission and occluded subsequent induction of LTP. Finally, we found that LTP was blocked by protein kinase A (PKA) inhibitors. Our results suggest that excitatory synapses on SS interneurons express a presynaptic form of LTP that is not dependent on NMDARs or postsynaptic Ca(2+) rise but is dependent on the cAMP-PKA signaling pathway.

Surgical treatment of the extratemporal epilepsies.

Epilepsy that originates outside of the temporal lobe can present some of the most challenging problems for surgical therapy. These epilepsies can be broadly categorized as lesional or non-lesional, with the nonlesional cases being the most difficult to localize. Lesional cases can result from malformations of cortical development, tumors, vascular malformations, or areas of old injury. Some lesions, such as focal cortical dysplasia, can be challenging, in that the boundaries of the pathology can be difficult to define. Presurgical goals include defining the structural lesion, the physiologic abnormality, and normal function in the area. These goals can be achieved using a variety of noninvasive and invasive tests. Surgical techniques vary depending on location and pathology but they always include removal of the epileptic brain tissue while preserving en passage vessels and underlying white matter tracts. Surgical outcomes vary depending on the underlying pathology. Surgeries are usually planned with a goal of no expected postoperative deficits, although temporary deficits may be anticipated in some areas, such as the supplementary motor cortex. Extratemporal epilepsy can be managed well with surgical treatment; but proper patient selection, evaluation, and discussion of expected outcomes and risks are critical in this challenging patient population.

Seizure recurrence following epilepsy surgery: is post-operative EEG helpful?

OBJECTIVES: We examined whether the relationship between interictal epileptiform discharges (IED) on post-operative EEG and seizure recurrence after epilepsy surgery was different in patients with neocortical and mesiotemporal resections. METHODS: We reviewed the records of 93 consecutive patients who underwent epilepsy surgery at our center and who had adequate post-operative follow-up and a post-operative EEG to determine the type of surgery, the recurrence of seizures and the presence of IED on post-operative EEG. RESULTS: Chi-square test revealed that for the entire group, there was a significant relationship between the presence of IED and seizure recurrence. However, this relationship was significant in neocortical surgery but not in mesiotemporal surgery. Time distribution of seizure recurrence revealed that in more than half the cases, seizures recurred with the first 3 months. Time distribution was not influenced by the presence of IED. CONCLUSIONS: This study revealed that IED on early post-operative EEG correlate with seizure recurrence in neocortical but not mesiotemporal surgeries and may be used to guide patient counseling in this group of patients.

Basic mechanisms of MCD in animal models.

Epilepsy-associated glioneuronal malformations (malformations of cortical development [MCD]) include focal cortical dysplasias (FCD) and highly differentiated glioneuronal tumors, most frequently gangliogliomas. The neuropathological findings are variable but suggest aberrant proliferation, migration, and differentiation of neural precursor cells as essential pathogenetic elements. Recent advances in animal models for MCDs allow new insights in the molecular pathogenesis of these epilepsy-associated lesions. Novel approaches, presented here, comprise RNA interference strategies to generate and study experimental models of subcortical band heterotopia and study functional aspects of aberrantly shaped and positioned neurons. Exciting analyses address impaired NMDA receptor expression in FCD animal models compared to human FCDs and excitatory imbalances in MCD animal models such as lissencephaly gene ablated mice as well as in utero irradiated rats. An improved understanding of relevant pathomechanisms will advance the development of targeted treatment strategies for epilepsy-associated malformations.

Two Groups of eGFP-Expressing Neurons with Distinct Characteristics in the Neocortex of GIN Mice.

GIN (GFP-expressing inhibitory interneuron) transgenic mice are believed to express the enhanced GFP (eGFP) in a subset of somatostatin (SST)-expressing interneurons in the neocortex and have been widely used in the study on SST interneurons. Previous studies showed that eGFP+ neurons in the neocortex are distributed in the layer II-IV and upper layer V (cortical eGFP neurons) and contain SST. In this study, we reported a new group of eGFP+ neurons in GIN mice at early postnatal ages, which was located in the deep layer of the lateral neocortex as clusters (cluster eGFP neurons). Cluster eGFP neurons were noticeable at birth but disappeared within two months, in contrast to cortical eGFP neurons that started to appear around postnatal day 3 to 5 and existed through life. Cluster eGFP neurons were not immunoreactive for SST antibodies, contrary to cortical eGFP neurons. They were also not immunolabeled by parvalbumin, a marker for another major type of interneurons, and Ca2+/calmodulin-dependent kinases II, a commonly used marker for excitatory neurons. Firing rate, afterhyperpolarization, and excitatory synaptic activity significantly enhanced in cortical eGFP neurons during postnatal development, but these properties remained mostly unchanged in cluster eGFP neurons. Short-term plasticity of the excitatory synapse showed robust facilitation in cortical eGFP neurons but depression in cluster eGFP neurons. These results implied that eGFP might also be expressed in other types of cortical neurons in addition to SST-containing interneurons in GIN mice at early postnatal ages.

Non-invasive imaging of epileptic seizures in vivo using photoacoustic tomography.

Non-invasive laser-induced photoacoustic tomography (PAT) is an emerging imaging modality that has the potential to image the dynamic function of the brain due to its unique ability of imaging biological tissues with high optical contrast and ultrasound resolution. Here we report the first application of our finite-element-based PAT for imaging of epileptic seizures in an animal model. In vivo photoacoustic images were obtained in rats with focal seizures induced by microinjection of bicuculline, a GABA(A) antagonist, into the neocortex. The seizure focus was accurately localized by PAT as confirmed with gold-standard electroencephalogram (EEG). Compared to the existing neuroimaging modalities, PAT not only has the unprecedented advantage of high spatial and temporal resolution in a single imaging modality, but also is portable and low in cost, making it possible to bring brain imaging to the bedside.

Superior divisional third cranial nerve paresis: clinical and anatomical observations of 2 unique cases.

BACKGROUND: Within the midbrain, the third nerve nucleus is composed of a complex of subnuclei. The fascicular portion of the nerve courses through the red nucleus and exists in the midbrain just medial to the cerebral peduncle. The cisternal portion of the nerve is a single structure that divides into a superior branch and an inferior branch in the region of the cavernous sinus and superior orbital fissure. OBJECTIVE: To describe 2 patients with superior divisional third cranial nerve paresis resulting from a lesion involving the cisternal portion of the nerve prior to its anatomical bifurcation. PATIENTS: Case 1 was a 77-year-old man with a superior divisional third nerve palsy as the presenting manifestation of a posterior communicating artery aneurysm. Case 2 was a 41-year-old woman who developed a superior divisional third nerve palsy following anterior temporal lobectomy for epilepsy. RESULTS: In both cases, the presumed location of the lesion was the cisternal portion of the third cranial nerve. CONCLUSIONS: Although the anatomical division of the third cranial nerve occurs in the region of the anterior cavernous sinus or superior orbital fissure, there is a topographical arrangement of the motor fibers within the cisternal portion of the nerve. The clinical evaluation of a patient with a third cranial nerve paresis requires an understanding of the regional neuroanatomy and topographical organization of the nerve.