The Resolution of Oculomotor Nerve Palsy Caused by Unruptured Posterior Communicating Artery Aneurysms: A Cohort Study and Narrative Review

An overview of decision-making in cerebrovascular treatment strategies: Part I - unruptured aneurysms

Introduction

Unruptured intracranial aneurysm treatment has evolved over the last two centuries, starting from the introduction of aneurysm ligation and clipping, up until the inception of endovascular treatment and further advancements in both fields.

Research question

The wide variety of aneurysm presentations and possible treatment modalities, complicates the understanding of decision-making for the treatment of a given aneurysm. The goal of this article is to provide an overview of the best available evidence concerning unruptured intracranial aneurysm decision-making and identify insights and hiatuses, as well as providing a scaffold to surpass the subjectiveness of decision-making.

Materials and methods

A literature review was performed for the most impactful articles on decision-making in unruptured intracranial aneurysm treatment, to provide an overview on current practice.

Results

Two groups of decision-altering factors were identified; patient-related and aneurysm-related factors. A summary is presented of the general evidence, and the influence of age, aneurysmal mass-effect, as well as size, morphological aspects and specific anatomical locations on decision-making.

Discussion and conclusion

Decision-making for an unruptured intracranial aneurysm often comes down to combining these different patient- and aneurysm-related factors. In this paper, an evidence-based overview is provided into these different factors which alter management of unruptured saccular aneurysms.

Impact of Diplopia and Ptosis From Lingering Third Nerve Palsy After Treatment of Cerebral Aneurysms

BACKGROUND

Third nerve palsies (TNPs) may not resolve after intervention for intracranial aneurysms that have compressed the nerve. The disability related to this lingering condition has not been assessed with the support of patient self-report.

METHODS

A single-institutional retrospective study of patients with TNP who had undergone interventions for intracranial aneurysms. We used residual primary-position diplopia, a narrow zone of single binocular vision, and vision-obscuring ptosis to divide TNP recovery into complete, incomplete nondisabling, and incomplete disabling outcomes based on medical record documentation and patient self-report derived from telephonic interviews.

RESULTS

In a cohort of 33 patients, 13 (39%) had complete TNP recovery. There were 11 patients (33%) with lingering visual disability from diplopia or ptosis present before ophthalmic interventions. Of the 6 patients who underwent ophthalmic interventions, visual disability was relieved in only 2 patients, leaving 9 patients (27%) with lingering impairment in instrumental activities of daily living. Telephonic interviews of 23 patients (70% of the cohort) confirmed that the outcome criteria we applied were accurate in assessing visual disability in 17 patients (74%). Univariate analysis using the Fisher exact test showed that aneurysmal clipping as a treatment modality was the only clinical feature associated with a favorable TNP outcome.

CONCLUSIONS

In applying a novel method of assessing disability, this study showed that more than one-quarter of patients undergoing procedures for brain aneurysms had lingering disability from third nerve palsy-associated diplopia or ptosis, despite later ophthalmic interventions. Patient self-report gleaned from telephonic interviews was valuable in largely validating the assessment method derived from medical records and in revealing differences between physician and patient estimation of disability.

Cranial nerve palsies and intracranial aneurysms: A narrative review of patterns and outcomes

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.

Recovery of Oculomotor Nerve Palsy After Surgical and Endovascular Repair of Unruptured Internal Carotid-Posterior Communicating Artery Aneurysms

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.

Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020

BACKGROUND

The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time.

METHODS

A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests.

RESULTS

A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987.

CONCLUSIONS

The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.

Posterior Communicating Artery Aneurysm With Referred Tooth Pain: A Case Report

Oculomotor nerve (CN III) palsy (ONP) has multiple etiologies, with aneurysms and ischemic injury being the two leading causes. The presentations of these conditions differ, as aneurysms commonly manifest with pupillary involvement, while ischemic-related ONP often leads to a pupil-sparing presentation. We present a 63-year-old African American male with a history of sickle cell trait, ocular sickle cell disease, and untreated hypertension that develops "down and out" left eye with a mid-dilated pupil unresponsive to light. However, the patient developed severe left upper tooth pain after the onset of the eye pain, which progressed to ONP. The patient's dental and radiographic evaluation did not indicate any obvious source for his tooth pain. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the head revealed a 7-mm saccular aneurysm with a 2-mm neck arising from the left posterior communicating artery (PCOM) aneurysm, and neurovascular surgical intervention was initiated. This case highlights the potential of referred tooth pain as an early symptom in patients with PCOM aneurysm, which physicians should be vigilant about and consider as a potential indicator of the condition. Therefore, collaboration between different specialties, including ophthalmology, neurology, neurosurgery, and dental care, is necessary to formulate a comprehensive treatment plan that effectively addresses the patient's specific needs and challenges.

Risks for Oculomotor Nerve Palsy and Time to Recovery After Surgical Clipping of Posterior Communicating Artery Aneurysms: A Multicenter Retrospective Cohort Study

BACKGROUND

Aneurysms of the posterior communicating segment of carotid artery (PcomA) have a high risk of rupture; when these nonruptured aneurysms are associated with oculomotor nerve palsy (ONP), the risk of rupture increases compared with asymptomatic nonruptured PcomA.

OBJECTIVE

To retrospectively analyze the risk factors involved in ONP secondary to PcomA aneurysm and to study the factors involved in the recovery time of ONP once it is established.

METHODS

This was a retrospective study of patients from 10 neurosurgery centers from October 2008 to December 2020. We analyzed age at diagnosis, presence of compressive neuropathy of the oculomotor nerve, presence of aneurysm rupture, largest aneurysm diameter, aneurysm projection, smoking, hypertension, diabetes, time between diagnosis and surgical treatment, as well as the outcome.

RESULTS

Approximately 1 in 5 patients (119/511 23.3%) with a PcomA presented with ONP. We found that patients with aneurysms measuring greater than or equal to 7.5 mm were 1.6 times more likely to have ONP than those with aneurysms smaller than 7.5 mm. In our study, the prevalence of smoking in the PcomA + ONP group was 57.76%, and we also found that smokers were 2.51 times more likely to develop ONP. A total of 80.7% showed some degree of improvement, and 45.4% showed complete improvement with a median recovery time of 90 days.

CONCLUSION

This study showed that 80.7% of patients with PcomA aneurysms undergoing surgical treatment with aneurysm clipping showed some degree of improvement of the ONP, with a median time to recovery between 90 and 120 days.

Stent-assisted coiling using the Neuroform Atlas stent for treatment of aneurysms that recur after coil embolization

Objective

To evaluate the safety and efficacy of stent-assisted coiling (SAC) using the Neuroform Atlas stent for aneurysms that recur after coil embolization.

Methods

We retrospectively reviewed patients who underwent SAC using the Neuroform Atlas stent to treat aneurysms that recurred after coil embolization from November 2020 to November 2021. Patient and aneurysm characteristics, procedural details, complications, and angiographic and clinical follow-up outcomes were recorded and analyzed.

Results

Eleven patients with 11 recurrent aneurysms were included for analysis. Atlas stent deployment was successful in all cases. Angiography immediately after the SAC procedure and at last follow-up showed complete occlusion in 10 patients (90.9%) and a residual neck in one (9.1%). Mean angiographic and clinical follow-ups were 9.2 and 10 months, respectively. A single procedure-related complication occurred, mildly blurred vision in the left eye, which recovered completely. No permanent morbidity or mortality occurred.

Conclusion

SAC using the Atlas stent to treat aneurysms that recur after coil embolization is safe and effective. Large-scale studies with long-term follow-up are warranted to confirm our results.

Nomogram model for predicting oculomotor nerve palsy in patients with intracranial aneurysm

AIM

To explore the risk factors of oculomotor nerve palsy (ONP) in patients with intracranial aneurysm (IA) and develop a nomogram model for predicting ONP of IA patients.

METHODS

A total of 329 IA patients were included. Logistic regression analysis was applied to identify independent factors, which were then integrated into the nomogram model. The performance of the nomogram model was evaluated by calibration curve, receiver operating curve (ROC), and decision curve analysis.

RESULTS

Univariate and multivariate logistic regression analysis indicated posterior communicating artery (PCoA) aneurysm [hazard ratio (HR)=17.13, P<0.001] and aneurysm diameter (HR=1.31, P<0.001) were independent risk factors of ONP in IA patients. Based on the results of logistic regression analysis, a nomogram model for predicting the ONP in IA patients was constructed. The calibration curve indicated the nomogram had a good agreement between the predictions and observations. The nomogram showed a high predictive accuracy and discriminative ability with an area under the curve (AUC) of 0.863. The decision curve analysis showed that the nomogram was powerful in the clinical decision. PCoA aneurysm (HR=3.38, P=0.015) was identified to be the only independent risk factor for ONP severity.

CONCLUSION

PCoA aneurysm and aneurysm diameter are independent risk factors of ONP in IA patients. The nomogram established is performed reliably and accurately for predicting ONP. PCoA aneurysm is the only independent risk factor for ONP severity.

Efficacy and long-term results of endovascular embolization and surgical clipping for posterior communicating artery unruptured aneurysms complicated with oculomotor nerve palsy

to investigate the efficacy and long-term outcomes of endovascular embolization and surgical clipping for patients with posterior communicating artery unruptured aneurysms (PcomAs) concomitant with oculomotor nerve palsy (ONP). No significant (P > .05) difference existed in the age, gender, proportion of complete ONP, and size of eye fissure and pupil before treatment between 2 groups. After compared with before treatment, the eye fissure was widened significantly (P < .05) and the pupil narrowed significantly (P < .05), but no significant (P > .05) differences existed between the 2 groups. Complete ONP recovery was observed in 32 (80%) patients in the embolization group and 31 (77.5%) in the microsurgical group, partial ONP recovery occurred in 6 (15%) in the embolization group and 8 (20%) in the microsurgical group. The recovery rate was 95% in the embolization group and 97.5% in the microsurgical group, with no significant (P > .05) difference between 2 groups. The recovery rate of the ONP was significantly (P < .01) greater in the microsurgical group than that in the embolization group at follow-up of 1 month, 3 months, six and 12 months, respectively. At 18 months, the ONP recovery rate was not significantly different between 2 groups (95% vs 97.5%) Surgical clipping may have a faster effect on the recovery of oculomotor nerve palsy than endovascular embolization for patients with posterior communicating artery unruptured aneurysms complicated with oculomotor nerve palsy, but both approaches may result in a similar effect on the nerve recovery in the long run.Eighty patients treated with endovascular embolization or surgical clipping were retrospectively enrolled into the endovascular embolization group or surgical clipping and analyzed.

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.

Clipping versus coiling in the treatment of oculomotor nerve palsy induced by unruptured posterior communicating artery aneurysms: A meta-analysis of cohort studies

BACKGROUND

Although the superiority of clipping compared to coiling on the oculomotor nerve palsy (ONP) recovery for ruptured posterior communicating artery aneurysms (PcomAAs) has been widely accepted, which treatment modality is better in the treatment of ONP induced by unruptured PcomAAs still remains unclear.

METHODS

A meta-analysis of studies that compared clipping with coiling was performed after a literature search. Perioperative data and clinical outcome were extracted. Analysis on the effect of the two treatment modalities was then performed.

RESULTS

Nine eligible studies with a total of 136 patients met the inclusion criteria. There was a significant difference in the total efficiency (any degree of improvement) on ONP favoring clipping [RR= 1.21, 95%CI (1.01, 1.44), p = 0.04], the effect was most notable for complete recovery of ONP after having suffered preoperative partial palsy [RR= 0.72, 95%CI (0.55, 0.95), p = 0.02]. There was neither a significant difference regarding the complete recovery of ONP [RR= 1.11, 95%CI (0.77, 1.61), p = 0.58] nor the frequency of complications [RR= 0.07, 95%CI (0.00, 1.10), p = 0.06]. Also when subdividing there was no significant difference in complete recovery of ONP in patients who had initially suffered a complete ONP [RR= 0.79, 95%CI (0.38, 1.64), p = 0.53] and partial ONP [RR= 1.16, 95%CI (0.65, 2.08), p = 0.61] between clipping and coiling.

CONCLUSIONS

A superiority of clipping over coiling for the improvement of ONP secondary to unruptured PcomAAs was found. Patients with partial ONP were more likely to attain a complete resolution of ONP, as compared to complete ONP.

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.

Comparison of surgical clipping and endovascular coiling in the treatment of oculomotor nerve palsy caused by posterior communicating artery aneurysm

Oculomotor nerve palsy (ONP) caused by posterior communicating aneurysm (PcomAA) is mainly treated by surgical clipping or endovascular coiling. However, there are still some controversies about which treatment method could provide the more beneficial prognosis. This study aimed to compare ONP recovery rate between surgical clipping and endovascular coiling in patients diagnosed as PcomAA combined with ONP, and explore the potential risk factors of ONP recovery.The clinical data of 152 patients with ONP caused by PcomAA were retrospectively analyzed. Diameter of aneurysm, different treatment methods (surgical clipping or endovascular coiling), subarachnoid hemorrhage (SAH), degree of preoperative ONP, time from ONP onset to treatment, as well as degree of ONP symptom recovery were collected from medical records. All patients were followed up for at least 1 year.One hundred twelve patients underwent surgical clipping and 40 patients received endovascular coiling. There were no significant differences in age, gender, aneurysm diameter, hypertension, dyslipidemia, time from ONP symptom onset to treatment, SAH, and preoperative ONP degree between the 2 groups (all P > .05). Time to complete or partial recovery was 86.7 ± 35.7 days for patients receiving surgical clipping and 132.6 ± 37.5 days for patients receiving endovascular coiling, respectively (Log rank test, P < .001). The recovery rate was 94.6% in the surgical clipping group and 65.0% in the endovascular coiling group. The difference between the two groups was statistically significant (P < .001). Postoperative ONP recovery in the surgical clipping group was significantly superior to that of patients in the endovascular coiling group (HR, 2.625; 95% CI: 1.423-4.841; P = .002). Time from ONP symptom onset to treatment exerted the obvious effect on the ONP prognosis (HR, 0.572; 95% CI: 0.384-0.852; P = .006). In addition, the ONP recovery in patients with SAH before surgery was also independently associated with ONP prognosis (HR, 1.276; 95% CI, 1.043-1.562; P = .018). There was no treatment-related death in either group, and postoperative complications were within the manageable range.The recovery rate and recovery degree of ONP after surgical clipping was significantly better than that of endovascular coiling in PcomAA patients combined with ONP. The postoperative ONP recovery was associated with preoperative spontaneous SAH and time from ONP onset to treatment.

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.

Acute Oculomotor Nerve Palsy Caused by Compression from an Aberrant Posterior Communicating Artery

Oculomotor nerve palsy (ONP) is a rare neurological deficit associated with numerous underlying pathologies. Of these, aneurysm of the posterior communicating artery (PCOM) has been described due to the intimate association with the third cranial nerve in the basal cistern. Less described are other vascular abnormalities and their contribution to ONP. We describe a case of ONP thought to result from a PCOM aneurysm, per the associated magnetic resonance imaging (MRI) scan, yet found intraoperatively to be caused by a congenital vascular aberrancy. This is the first case, to our knowledge, of this presentation.

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.