To wait for a spontaneous recovery of the third cranial nerve palsy occurring after the coiling of a PComA aneurysm or to implement surgical treatment? – A case report

Miodrag Peulić; Vojin Stevo Kovačević; Marina Miletić Kovačević; Danica Grujičić

doi:10.2298/VSP160317235P

Miodrag Peulić Clinical Center Kragujevac, Center for Neurosurgery, Kragujevac, Serbia; University of Kragujevac, Faculty of Medical Sciences, Department of Surgery, Kragujevac, Serbia
Vojin Stevo Kovačević Clinical Center Kragujevac, Center for Neurosurgery, Kragujevac, Serbia; University of Kragujevac, Faculty of Medical Sciences, Department of Surgery, Kragujevac, Serbia
Marina Miletić Kovačević University of Kragujevac, Faculty of Medical Sciences, Department of Surgery, Kragujevac, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Danica Grujičić Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP160317235P

Keywords: intracranial aneursym, oculomotor nerve, embolization, therapeutic, neurosurgical procedures, ophthalmoplegia, recovery of function,

Abstract

Introduction. In the last two decades a method of endovascular embolization has been imposed as a method of choice in the treatment of unruptured intracranial aneurysms. Therefore, the problem of treating posterior communicating artery (PComA) aneurysms presenting with the third cranial nerve (TCN) palsy has become even more complex. The case of a patient reported in the paper itself has presented a dilemma of whether to wait for spontaneous resolution of ophthalmoplegia developed after the coiling of a PComA aneurysm or whether to implement an early surgical treatment. Case report. An unruptured saccular aneurysm, directed inferolaterally in the right internal carotid artery (ICA) segment in the position of the PcomA origin, was diagnosed in a 58-year-old male patient. The aneurysm was measuring 9 mm in diameter while the neck was measuring 5 mm. The day before the planned embolization, the patient developed ipsilateral ophthalmoparesis, whereas the first day after the endovascular procedure was completed, the patient developed right-sided complete ophthalmoplegia. Ten weeks after the endovascular embolization our team decided to perform a microsurgical treatment including aneurysm clipping and coil extraction. Eighteen months after the surgery, the patient made a full recovery of the functions of musculus (m) levator palpabrae, m. rectus medialis and pupillary function, with a partial recovery of the functions of m. obliqus inferior, m. rectus inferior and m. rectus superior. Conclusion. According to medical research and literature, the partial recovery of the TCN palsy is expected to happen in the first few weeks after embolization. Despite the completion of endovascular treatment progression of ophthalmoparesis to ophthalmoplegia without any simptoms of clinical improvement after 10 weeks is considered to be an indicator of long-standing TCN compression, which can lead to irreversible nerve damage. Despite the increase in the use of an endovascular embolization method in the treatment of PComA aneurysms preceeded by the TCN palsy, neurosurgical treatment is believed to have been necessary. Still, there is one question left to be answered - did we react too late in this particular case?

References

Morris Z, Whiteley WN, Longstreth WT Jr, Weber F, Lee YC, Tsushima Y, et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009; 339: b3016.

Good EF. Ptosis as the sole manifestation of compression of the oculomotor nerve by an aneurysm of the posterior communicating artery. J Clin Neuroophthalmol 1990; 10(1): 59–61.

Lanzino G, Andreoli A, Tognetti F, Limoni P, Calbucci F, Bortolami R, et al. Orbital pain and unruptured carotid-posterior communicating artery aneurysms: the role of sensory fibers of the third cranial nerve. Acta Neurochir (Wien) 1993; 120(1−2): 7−11.

Im SH, Han MH, Kwon OK, Kwon BJ, Kim SH, Kim JE, et al. Endovascular coil embolization of 435 small asymptomatic unruptured intracranial aneurysms: procedural morbidity and patient outcome. AJNR Am J Neuroradiol 2009; 30(1): 79−84.

Gu DQ, Luo B, Zhang X, Long XA, Duan CZ. Recovery of posterior communicating artery aneurysm-induced oculomotor nerve paresis after endovascular treatment. Clin Neurol Neurosurg 2012; 114(9): 1238−42.

Chalouhi N, Theofanis T, Jabbour P, Dumont AS, Gonzalez LF, Starke RM, et al. Endovascular treatment of posterior communicating artery aneurysms with oculomotor nerve palsy: clinical outcomes and predictors of nerve recovery. AJNR Am J Neuroradiol 2013; 34(4): 828−32.

Hanse MC, Gerrits MC, van Rooij WJ, Houben MP, Nijssen PC, Sluzewski M. Recovery of posterior communicating artery aneurysm-induced oculomotor palsy after coiling. AJNR Am J Neuroradiol 2008; 29(5): 988−90.

Nam KH, Choi CH, Lee JI, Ko JG, Lee TH, Lee SW. Unruptured Intracranial Aneurysms with Oculomotor Nerve Palsy : Clinical Outcome between Surgical Clipping and Coil Embolization. J Korean Neurosurg Soc 2010; 48(2): 109−14.

Golshani K, Ferrell A, Zomorodi A, Smith TP, Britz GW. A review of the management of posterior communicating artery aneurysms in the modern era. Surg Neurol Int 2010; 1: 88.

Khan SA, Agrawal A, Hailey CE, Smith TP, Gokhale S, Alexander MJ, et al. Effect of surgical clipping versus endovascular coiling on recovery from oculomotor nerve palsy in patients with posterior communicating artery aneurysms: A retrospective comparative study and meta-analysis. Asian J Neurosurg 2013; 8(3): 117−24.

van Rooij WJ, Sluzewski M. Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms. AJNR Am J Neuroradiol 2006; 27(8): 1678−80.

Okawara SH. Warning signs prior to rupture of an intracranial aneurysm. J Neurosurg. 1973; 38(5): 575−80.

Leivo S, Hernesniemi J, Luukkonen M, Vapalahti M. Early surgery improves the cure of aneurysm-induced oculomotor palsy. Surg Neurol 1996; 45(5): 430−4.

de Oliveira JG, Borba LA, Rassi-Neto A, de Moura SM, Sanchez-Júnior SL, Rassi MS, et al.. Intracranial aneurysms presenting with mass effect over the anterior optic pathways: neurosurgical management and outcomes. Neurosurg Focus 2009; 26(5): E3.

Chen PR, Amin-Hanjani S, Albuquerque FC, McDougall C, Zabramski JM, Spetzler RF. Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling. Neurosurgery 2006; 58(6): 1040−6; discussion 1040−6.

Nishino K, Ito Y, Hasegawa H, Shimbo J, Kikuchi B, Fujii Y. Development of cranial nerve palsy shortly after endosaccular embolization for asymptomatic cerebral aneurysm: report of two cases and literature review. Acta Neurochir (Wien) 2009; 151(4): 379−83.

Hamer J. Prognosis of oculomotor palsy in patients with aneurysms of the posterior communicating artery. Acta Neurochir (Wien) 1982; 66(3−4): 173−85.

He W, Gandhi CD, Quinn J, Karimi R, Prestigiacomo CJ. True an-eurysms of the posterior communicating artery: a systematic review and meta-analysis of individual patient data. World Neurosurg 2011; 75(1): 64−72; discussion 49.

Romani R, Lehto H, Laakso A, Horcajadas A, Kivisaari R, von und zu Fraunberg M, et al. Microsurgery for previously coiled aneurysms: experience with 81 patients. Neurosurgery 2011; 68(1): 140−53; discussion 153−4.

Waldron JS, Halbach VV, Lawton MT. Microsurgical management of ncompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 2009; 64(5 Suppl 2): 301−15; discussion 315−7.