Case 3

A 75-year-old man is transported to hospital by ambulance. He dialled 999 after experiencing severe central chest pain.

An ECG showed classical changes of an inferior myocardial infarction and he received pre-hospital thrombolysis.

Shortly after thrombolysis was commenced, he became confused, and was noted to be bradycardic and hypotensive. This resolved with a bolus of IV fluids, though he complained of the onset of an acute severe headache.

In the ED some three hours later, it became clear that the patient’s headache was unabated and he was unable to fully open his eyes. His speech was normal as were his cognitive functions and limb movements.

Examination showed bilateral ptosis. He was unable to move his eyes but he could see; though his peripheral vision was diminished. The corneal reflexes were intact.

All other cranial nerves were unaffected and peripheral nervous system examination was normal. Which of the following cranial nerves have been affected?

Which condition does the bilateral nature of the cranial nerve findings suggest?