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Hoz SS, Ma L, Muthana A, Al-Zaidy MF, Ahmed FO, Ismail M, Jacobs RC, Agarwal P, Al-Bayati AR, Nogueira RG, Lang MJ, Gross BA. Cranial nerve palsies and intracranial aneurysms: A narrative review of patterns and outcomes. Surg Neurol Int 2024; 15:277. [PMID: 39246770 PMCID: PMC11380827 DOI: 10.25259/sni_531_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 07/14/2024] [Indexed: 09/10/2024] Open
Abstract
Background Cranial nerve palsy (CNP) in patients with intracranial aneurysms (IAs) can impose significant burdens on a patient's quality of life. The literature has a paucity of reviews addressing patterns of overall reported cranial nerve (CN) involvement and outcomes in patients with IA. Methods The literature systematically reviewed CNP at presentation in the setting of IA using PubMed, Web-of-Science, and Scopus according to the PRISMA guidelines. Results Fifty-two studies reported a total of 513 patients with IA and 630 CNPs observed at presentation: oculomotor (58.25%), abducent (15.87%), optic (12.06%), trochlear (8.7%), and trigeminal (1.9%). Most common aneurysms are located in a posterior communicating artery (46%) and cavernous internal carotid artery (29.2%). Trends of CNP based on the rupture status of IAs showed that 80% were associated with unruptured IAs and 20% with ruptured IAs. Post-treatment of IA, 55% of patients had complete resolution of CNP, with most (89%; n = 134) resolving within the first 6 months. Stratified by CNP type: Complete resolution rate is 100% in CN VII-IX, 60% in CN VI, 59% in CN IV, 54% in CN III, 45% in CN V, and 43% in CN II. Conclusion In patients with cranial nerve palsies attributed to IAs, the location and rupture status of the aneurysm could determine the type and severity of the nerve palsy. Most patients experienced favorable outcomes in terms of their resolution and long-term function of the CNP after treatment of the IA.
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Affiliation(s)
- Samer S Hoz
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Li Ma
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Ahmed Muthana
- Department of Neurosurgery, University of Baghdad, Baghdad, Iraq
| | | | | | - Mustafa Ismail
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | - Rachel C Jacobs
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Prateek Agarwal
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Alhamza R Al-Bayati
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, Pittsburgh, Pennsylvania, United States
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, Pittsburgh, Pennsylvania, United States
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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Tabata S, Take Y, Kimura T, Onodera K, Kume H, Fukuoka M, Suzuki K, Ooigawa H, Kohyama S, Kurita H. Recovery of Oculomotor Nerve Palsy After Surgical and Endovascular Repair of Unruptured Internal Carotid-Posterior Communicating Artery Aneurysms. World Neurosurg 2024; 188:e334-e340. [PMID: 38796144 DOI: 10.1016/j.wneu.2024.05.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Unruptured posterior communicating artery (Pcom) aneurysms cause oculomotor nerve palsy (ONP). However, the time course of recovery after aneurysm repair remains unclear. We aimed to evaluate the ONP course after clipping and coiling for unruptured Pcom aneurysms. METHODS We retrospectively reviewed the medical records of 25 consecutive patients with ONP due to unruptured Pcom aneurysms, undergoing aneurysm repair at our institution during 2010-2022. We analyzed the clinical data, angiographic results, and surgical complications. The time to ONP recovery was evaluated using the Kaplan-Meier method. RESULTS This study included 14 patients undergoing surgical clipping and 11 undergoing endovascular coiling. The two groups exhibited no significant differences in complete or partial ONP percentage or in symptom presentation (ptosis, diplopia, ocular paralysis, pupillary light reflex disorder, or mydriasis). All patients achieved complete or partial recovery during the follow-up period. The median time to partial or complete improvement in ONP was significantly shorter for clipping compared to coiling (2 days vs. 33 days; P = 0.009). Preoperative partial and complete ONP were stratified; clipping improved significantly earlier than coiling in the complete ONP group (P = 0.010). In the early treatment group (based on the median duration of treatment), clipping resulted in earlier improvement than coiling (P = 0.014). In the small aneurysm group (based on the median of the aneurysm maximum diameter), clipping resulted in earlier improvement than coiling (P = 0.005). CONCLUSION In ONP caused by an unruptured Pcom aneurysm, clipping may provide faster recovery than coiling, particularly in cases of early onset, complete palsy, and small aneurysms.
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Affiliation(s)
- Shinya Tabata
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Yushiro Take
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan.
| | - Tatsuki Kimura
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Koki Onodera
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Haruka Kume
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Masayoshi Fukuoka
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Hidetoshi Ooigawa
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Shinya Kohyama
- Department of Endovascular Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
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Zheng J, Wan Y. Internal carotid artery aneurysm with incomplete isolated oculomotor nerve palsy: a case report. J Med Case Rep 2023; 17:77. [PMID: 36805779 PMCID: PMC9940366 DOI: 10.1186/s13256-023-03758-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/02/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Oculomotor nerve palsy is a common and well-described disease with diverse etiologies. Clinicians should quickly and correctly diagnose and treat oculomotor nerve palsy according to its characteristics and the accompanying symptoms and signs. Intracranial aneurysm is an important and frequent cause of oculomotor nerve palsy. Considering the catastrophic consequences of rupture, the possibility of an urgent, life-threatening disease should always be considered. CASE PRESENTATION A 63-year-old Chinese woman presented with intermittent left ptosis and diplopia and painless incomplete oculomotor nerve palsy without pupil involvement. She manifested no mydriasis or extraocular muscle weakness, and the light reflex was normal. Other cranial nerves and somatosensory and somatomotor examinations were normal. The neostigmine experiment and electromyography were normal, so the diagnosis of myasthenia gravis was excluded. Brain magnetic resonance angiography showed a 4-mm aneurysm located at the cavernous segment of the left internal carotid artery. Unfortunately, the patient refused digital subtraction angiography and was discharged home without further treatment. CONCLUSION Neuroimaging must be performed to exclude intracranial aneurysms in oculomotor nerve palsy regardless of whether the pupils are involved, as aneurysm rupture carries substantial morbidity and mortality.
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Affiliation(s)
- Jing Zheng
- grid.477399.7The Third People’s Hospital of Hubei Province, Wuhan, Hubei China
| | - Yue Wan
- The Third People's Hospital of Hubei Province, Wuhan, Hubei, China.
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Signorelli F, Pop R, Ganau M, Cebula H, Scibilia A, Gallinaro P, Zaed I, Todeschi J, Lefevre E, Nannavecchia B, Severac F, Coca HA, Turjman F, Maduri R, Beaujeux R, Proust F, Chibarro S. Endovascular versus surgical treatment for improvement of oculomotor nerve palsy caused by unruptured posterior communicating artery aneurysms. J Neurointerv Surg 2020; 12:964-967. [DOI: 10.1136/neurintsurg-2020-015802] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 11/04/2022]
Abstract
BackgroundThere 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 methodsA 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.ResultsWe 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).ConclusionThere 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.
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[Patients with subarachnoid haemorrhage in poor grade neurological status: Study of prognostic factors]. Neurocirugia (Astur) 2014; 26:32-8. [PMID: 25455762 DOI: 10.1016/j.neucir.2014.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 07/31/2014] [Accepted: 09/22/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate and predict factors influencing prognosis and/or clinical outcome at 6 months in patients with spontaneous subarachnoid haemorrhage, World Federation of Neurosurgical Societies (WFNS) grades iv and v. MATERIAL AND METHODS This was a retrospective study of a consecutive series of 394 patients admitted to our hospital with clinical and radiological diagnosis of spontaneous subarachnoid haemorrhage, from 1 January 1999 to 30 June 2009. We selected 121 patients who met the criteria of being in WFNS grades iv or v before treatment; 3 patients were excluded due to loss of tracking. The outcome variable was assessed 6 months after the event using the Glasgow Outcome Scale. A P value<.05 was considered statistically significant. RESULTS One hundred and twenty-one patients were included in the statistical analysis. The average age of the patients in the series was 54 years (14-92). Patients who had a mean Glasgow Coma Scale lower than 7 points (P<.0001), those who were grade v (P<.0001) in the pre-treatment WFNS scale and those with pupillary disorder (P=.002) had a worse clinical outcome. Likewise, those with associated intraparenchymal hematoma (P=.020) and those not receiving any treatment (P=.020) were also associated with a poor clinical outcome. These results were statistically significant. CONCLUSIONS Patients admitted with a WFNS grade v and/or presenting pupil disorder and/or intraparenchymal hematoma were associated with worse clinical outcomes.
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Anan M, Nagai Y, Fudaba H, Kubo T, Ishii K, Murata K, Hisamitsu Y, Kawano Y, Hori Y, Nagatomi H, Abe T, Fujiki M. Third nerve palsy caused by compression of the posterior communicating artery aneurysm does not depend on the size of the aneurysm, but on the distance between the ICA and the anterior–posterior clinoid process. Clin Neurol Neurosurg 2014; 123:169-73. [DOI: 10.1016/j.clineuro.2014.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 04/12/2014] [Accepted: 05/04/2014] [Indexed: 10/25/2022]
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Tilikete C, Vighetto A. When is diplopia strongly suggestive of a vascular event? EXPERT REVIEW OF OPHTHALMOLOGY 2009. [DOI: 10.1586/eop.09.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Multidetector Computed Tomographic Angiography in Isolated Third Nerve Palsy. Ophthalmology 2008; 115:1411-5. [DOI: 10.1016/j.ophtha.2007.12.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 12/15/2007] [Accepted: 12/18/2007] [Indexed: 11/24/2022] Open
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Tsang JP, Wong GK, Ng SC, Poon WS. Recovery of isolated third nerve palsy related to treatment of unruptured posterior communicating artery aneurysm. SURGICAL PRACTICE 2007. [DOI: 10.1111/j.1744-1633.2007.00370.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schultz KL, Lee AG. Diagnostic yield of the evaluation of isolated third nerve palsy in adults. Can J Ophthalmol 2007. [DOI: 10.3129/can.j.ophthalmol.06-099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Kelley RE, Gonzalez-Toledo E. Stroke. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2005; 67:203-38. [PMID: 16291024 DOI: 10.1016/s0074-7742(05)67007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Roger E Kelley
- Department of Neurology, Louisiana State University Health Sciences Center Shreveport, Louisiana 71103, USA
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Abstract
We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.
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Affiliation(s)
- A Vighetto
- Service de Neurologie D, Hôpital neurologique Pierre-Wertheimer et Université Claude-Bernard Lyon I, Lyon.
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