Oculomotor nerve palsy induced by internal carotid artery aneurysm: prognostic factors for recovery

Flow diversion for internal carotid artery aneurysms with compressive neuro-ophthalmologic symptoms: clinical and anatomical results in an international multicenter study

BACKGROUND

Scientific data on the safety and efficacy of flow diverter stents (FDS) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms are scarce. We studied this subject in a retrospective international multicenter series, pooling data of 9 tertiary care neurointerventional departments.

OBJECTIVE

To investigate, in a retrospective, multicentric cohort of patients presenting with visual or oculomotor symptoms attributed to a compressive carotid artery in an unruptured intracranial aneurysm, the safety and efficacy profiles of FDS, by analyzing neuro-opthalmologic symptom evolution following FDS placement, complications, and aneurysm obliteration rates.

METHODS

All patients treated since 2015 with a FDS for an unruptured aneurysm of the ICA with signs of compressive cranial nerve symptoms (CN II, III, IV, VI) were included.

RESULTS

We treated 55 patients with 55 aneurysms; 21 (38.2%) patients had oculomotor and 15 (27.3%) visual symptoms only; 19 (34.5%) presented with a combination of both. Treatment-related morbidity/mortality occurred in 7.2% and 3.6%, respectively. At last imaging follow-up (13.1±10.5 months) rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 72%, 14%, and 14%, respectively. At last clinical follow-up after 13±10.5 months, 19/51 (37.3%) patients had recovered completely and 18/51 (35.3%) had recovered at least partially from their neuro-ophthalmological symptoms. In multivariable models, a longer delay between symptom onset and treatment was associated with higher odds for incomplete recovery and lower odds for any improvement (aOR 1.03 (95% CI 1.01 to 1.07), p=0.047 and 0.04 (0-0.81), p=0.020). Incomplete recovery was independently associated with older age and fusiform aneurysms.

CONCLUSION

FDS are effective to treat patients with compressive aneurysms of the ICA causing neuro-ophthalmological symptoms, especially when treatment is initiated early after symptom onset, and aneurysm occlusion is adequate. However, serious complications are not rare.

Clipping versus coiling for the treatment of oculomotor nerve palsy induced by posterior communicating artery aneurysms: A comparison of effectiveness

BACKGROUND

A long debate has been going on in the clinical effectiveness to determine whether surgical clipping or coiling more favorable for oculomotor nerve palsy (ONP) caused by PcomAA. We aimed to perform a study, focusing on the effectiveness of ONP induced by PcomAA after treatment of surgical clipping and endovascular coiling.

METHOD

Potential studies were searched on PubMed, EMBASE, Web of Science, and Cochrane Library from database inception to February 2021, and STATA version 12.0 was exerted to process the pooled data.

RESULTS

A total of 16 articles are included in the study, hailing from the United States, South Korea, the United Kingdom, France, Germany, Korea, China, Japan, Britain, and Singapore. The results showed that the clipping group was related to a higher incidence of complete ONP recovery at follow-up (OR = 5.808, 95% CI 2.87 to 11.76, p < 0.001), the lower rates of partial ONP recovery (OR = 0.264, 95% CI 0.173 to 0.402, p < .001) and no improvement of ONP at follow-up (RD = -0.149, 95% CI -0.247 to -0.051, p = .003). In the subgroup of complete ONP recovery based on the condition of patients, clipping was associated with a higher incidence of complete ONP recovery in patients with the incomplete initial ONP (OR = 3.579, p = .020) and ruptured aneurysm (OR = 5.38, p = .020). Regarding the subgroup of complete ONP recovery based on the quality of studies, similar results also appeared.

CONCLUSION

Surgical clipping was more favorable to the recovery from ONP caused by PcomAA endovascular coiling due to a higher rate of recovery and recovery degree of ONP. Besides that, more evidence-based performance is necessary to supplement this opinion.

Third Nerve Palsy Due to Intracranial Aneurysms and Recovery after Endovascular Coiling

INTRODUCTION

The modality of treatment of third nerve palsy (TNP) associated with intracranial aneurysms remains controversial. While treatment varies with the location of the aneurysm, microsurgical clipping of PComm aneurysms has generally been the traditional choice, with endovascular coiling emerging as a reasonable alternative.

METHODS

Patients with TNP due to an intracranial aneurysm who subsequently underwent treatment at a mid-sized Canadian neurosurgical center over a 15-year period (2003-2018) were examined.

RESULTS

A total of 616 intracranial aneurysms in 538 patients were treated; the majority underwent endovascular coiling with only 24 patients treated with surgical clipping. Only 37 patients (6.9%) presented with either a partial or complete TNP and underwent endovascular embolization; of these, 17 presented with a SAH secondary to intracranial aneurysm rupture. Aneurysms associated with TNP included PComm (64.9%), terminal ICA (29.7%), proximal MCA (2.7%), and basilar tip (2.7%) aneurysms. In general, smaller aneurysms and earlier treatment were provided for patients for ruptured aneurysms with a shorter mean interval to TNP recovery. In the endovascularly treated cohort initially presenting with TNP, seven presented with a complete TNP and the remaining were partial TNPs. TNP resolved completely in 20 patients (55.1%) and partially in 10 patients (27.0%). Neither time to coiling nor SAH at presentation were significantly associated with the recovery status of TNP.

CONCLUSION

Endovascular coil embolization is a viable treatment modality for patients presenting with an associated cranial nerve palsy.

Oculomotor nerve palsy due to posterior communicating artery aneurysm: Clipping vs coiling

OBJECTIVE

Posterior communicating artery aneurysms (PCoAA) usually present with brain hemorrhage, but they might present with oculomotor nerve palsy (ONP) in about one out of five patients. Treatment options include endovascular coiling and surgical clipping. The present analysis aims to compare the two treatment options for ONP due to PCoAA in terms of complete recovery and related parameters.

METHODS

A comprehensive literature search was performed for studies published between 2000 and 2019 on ONP due to PCoAA. The included studies were divided into two categories-surgical clipping (group A) and endovascular coiling (group B). The collected data were statistically processed with SPSS version 25.

RESULTS

There was a significant difference between the two treatment groups regarding complete recovery of ONP (P<0.001), suggesting superiority of the surgical clipping. The correlation analysis showed no correlations for group A. Group B had negative and positive correlations, showing that endovascular coiling results in higher rates of complete ONP recovery for elderly patients.

CONCLUSION

Surgical clipping is superior to endovascular coiling in terms of complete recovery among patients with ONP due to PCoAAs. Endovascular coiling seems to benefit older patients. While no recommendations exist for the treatment of ONP due to intracranial aneurysms, an increasing number of studies imply the superiority of operative clipping.

Endovascular versus surgical treatment for improvement of oculomotor nerve palsy caused by unruptured posterior communicating artery aneurysms

Background

There is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to assess predictors of ONP recovery in a multicenter series of consecutive patients.

Materials and methods

A retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses.

Results

We identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5–18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5–9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment <4 weeks, aneurysm recurrence during follow-up, and retreatment during follow-up were significantly correlated with ONP outcome in the univariate analysis. In the multivariate analysis, independent predictors of ONP improvement were interval to complete treatment <4 weeks (OR 5.15, 95% CI 1.37 to 23.71, p=0.015) and aneurysm recurrence during follow-up (OR 0.1, 95% CI 0.02 to 0.47, p=0.003).

Conclusion

There was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.

Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients

OBJECTIVE

Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome.

METHODS

In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death.

RESULTS

Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt.

CONCLUSIONS

Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.

The aetiologies of the unilateral oculomotor nerve palsy: a review of the literature

Oculomotor nerve palsy (ONP) is an important and common clinical diagnosis. Its main features are diplopia and ptosis. Its aetiologies are various and complex. A number of different conditions have been reported to cause ONP, such as diabetes mellitus, aneurysm, tumours, painful ophthalmoplegia, pituitary lesions, cavernous sinus lesions, central nervous system infections, and subarachnoid haemorrhage. A patients needs to undergo several tests in order to establish the correct underlying pathology. In this review, we have summarized the aetiologies of the unilateral ONP, and discussed their relative clinical features, pathogenesis, diagnostic criteria, treatment options, and prognosis. We searched PubMed for papers related to ONP and its aetiologies, and selected the publications, which seemed appropriate.

Intracranial Aneurysms of Neuro-Ophthalmologic Relevance

BACKGROUND

Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated.

EVIDENCE ACQUISITION

A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review.

RESULTS

Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters.

CONCLUSIONS

Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.

Clipping Versus Coiling in the Management of Posterior Communicating Artery Aneurysms with Third Nerve Palsy: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare surgical clipping with endovascular coiling in terms of recovery from oculomotor nerve palsy (ONP) in the management of posterior communicating artery (PCoA) aneurysms causing third nerve palsy.

METHODS

We conducted a systematic review of the literature and meta-analysis.

RESULTS

The meta-analysis included 11 relevant studies involving 384 patients with third nerve palsy caused by PCoA aneurysms at baseline, of whom 257 (67.0%) were treated by clipping and 127 were treated by coiling (33.0%). Pooled odds ratios of the impact of clipping or coiling on complete ONP recovery, lack of ONP recovery, and procedure-related death were calculated. The overall complete ONP recovery rate was 42.5% in the coiling group compared with 83.6% in the clipping group. The increase in complete ONP recovery in the clipping group corresponds to an overall pooled Mantel-Haenszel odds ratio of 4.44 (95% confidence interval = 1.66-11.84). Subgroup analysis revealed a clear benefit of clipping over coiling in patients with ruptured aneurysms, but not in patients with unruptured aneurysms. No procedure-related deaths were reported by any of the 11 studies.

CONCLUSIONS

Surgical clipping of PCoA aneurysms causing third nerve palsy achieves better ONP recovery than endovascular coiling; this could be particularly true in the case of ruptured aneurysms. In view of the purely observational data, statements about this effect should be made with great caution. A randomized trial would better address the therapeutic dilemma, but pending the results of such a trial, we recommend treating PCoA aneurysms causing ONP with surgery.