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This case presents sequential bilateral third cranial nerve involvement in paracetamol-induced ALF, complicated by severe hyperammonaemia and intracranial hypertension. The patient initially developed transient right-sided pupillary fixed dilation followed by left-sided oculomotor nerve palsy. She was managed with advanced neuroprotective measures, hyperosmolar therapy and tailored high-dose continuous renal replacement therapy (CRRT), leading to resolution of both the cerebral oedema and neurological deficits. This report highlights the importance of recognising cranial nerve palsies as a feature of ALF-induced intracranial hypertension and demonstrates the value of individualised multidisciplinary critical care therapeutic strategies. In addition, it emphasises the challenges of intracranial pressure monitoring in ALF and the need for further research on optimal CRRT protocols to improve outcomes in critically ill patients.<\/jats:p>","DOI":"10.1136\/bcr-2025-266430","type":"journal-article","created":{"date-parts":[[2025,6,8]],"date-time":"2025-06-08T15:40:15Z","timestamp":1749397215000},"page":"e266430","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Transient third nerve palsy in acute liver failure secondary to paracetamol overdose"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1374-2885","authenticated-orcid":false,"given":"H N","family":"Benaragama","sequence":"first","affiliation":[{"name":"John V Farman Intensive Care Unit, Addenbrooke\u2019s Hospital, Cambridge, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sumudu Samarathunga","family":"Liyanage","sequence":"additional","affiliation":[{"name":"John V Farman Intensive Care Unit, Addenbrooke\u2019s Hospital, Cambridge, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susan","family":"Stevenson","sequence":"additional","affiliation":[{"name":"John V Farman Intensive Care Unit, Addenbrooke\u2019s Hospital, Cambridge, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3211-3216","authenticated-orcid":false,"given":"Andrew","family":"Conway Morris","sequence":"additional","affiliation":[{"name":"Perioperative, Acute, Critical Care and Emergency Medicine Section, Department of Medicine, Cambridge University, Cambridge, UK"},{"name":"John V Farman Intensive Care Unit, Addenbrooke\u2019s Hospital, Cambridge, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,6,8]]},"reference":[{"key":"2025082707132051000_18.6.e266430.1","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1016\/j.mpaic.2023.10.016","article-title":"Acute liver failure","volume":"25","author":"Ordys","year":"2024","journal-title":"Anaesthesia & Intensive Care Medicine"},{"key":"2025082707132051000_18.6.e266430.2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2023.03.017"},{"key":"2025082707132051000_18.6.e266430.3","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1016\/S0140-6736(19)31894-X","article-title":"Acute liver failure","volume":"394","author":"Stravitz","year":"2019","journal-title":"The Lancet"},{"key":"2025082707132051000_18.6.e266430.4","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1016\/j.rgmxen.2024.05.002","article-title":"Acute liver failure: Management update and prognosis","volume":"89","author":"Mart\u00ednez-Mart\u00ednez","year":"2024","journal-title":"Revista de Gastroenterolog\u00eda de M\u00e9xico (English Edition)"},{"key":"2025082707132051000_18.6.e266430.5","doi-asserted-by":"publisher","DOI":"10.1186\/cc9002"},{"key":"2025082707132051000_18.6.e266430.6","doi-asserted-by":"crossref","unstructured":"Rucker JC , Dugue A . 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