Adult-onset migraine-related ophthalmoplegia and omolateral fetal-type posterior cerebral artery

Recurrent Painful Ophthalmoplegic Neuropathy: A case report with atypical features and a review of the literature

INTRODUCTION

Recurrent Painful Ophthalmoplegic Neuropathy, previously known as Ophthalmoplegic Migraine, is a poorly characterized disorder mainly because there are few cases described. We report a new case of Recurrent Painful Ophthalmoplegic Neuropathy and a review of the literature to contribute to increasing the knowledge of the clinical features of this disorder.

CASE REPORT AND REVIEW OF LITERATURE

A 45-year-old woman presented with adult-onset recurrent attacks of abducens and oculomotor palsy associated with diplopia followed by headache. Most notably, pain always presented many days after oculomotor impairment, a feature never described in the literature. A diagnosis of possible Recurrent Painful Ophthalmoplegic Neuropathy was made after excluding other possible mimicking disorders. Symptoms usually resolved gradually with corticosteroid therapy, albeit without a clear-cut benefit.Clinical data collected from 1989 to 2022 showed that adult onset in Recurrent Painful Ophthalmoplegic Neuropathy is not uncommon. While III cranial nerve palsy is typical, VI and IV nerve palsy have also been described.

PATHOPHYSIOLOGY AND DIAGNOSIS

Several hypotheses have been proposed, including nerve compression, ischemia or inflammation/demyelination, but none has been completely accepted.Diagnosis remains of exclusion; magnetic resonance imaging and blood exams are key in differential diagnosis.

CONCLUSIONS

Our case gives us the possibility to expand the clinical features of Recurrent Painful Ophthalmoplegic Neuropathy, also contributing to updating the pathophysiological hypotheses.

Role of Neurovascular Compression of Oculomotor Nerve in Ophthalmoplegic Migraine

Ophthalmoplegic migraine is considered to occur more commonly in children than in adults. It commonly affects the oculomotor nerve among the cranial nerves. Demyelination of the nerve is proposed as the main mechanism for the etiology of ophthalmoplegic migraine, though it is not fully understood. Neurovascular compression as a cause of ophthalmoplegic migraine has not been well demonstrated in children. In this report, we present a case of a 13-year-old male with recurrent episodes of left ophthalmoplegic migraine. Oculomotor nerve enhancement with swelling was evident on MRI at the exit zone. Magnetic resonance angiography (MRA) revealed a sharp loop of the left posterior cerebral artery compressing the nerve. The case highlighted the unusual etiology of neurovascular compression resulting in ophthalmoplegic migraine in a pediatric patient. A supplemental case of ophthalmoplegic migraine in a seven-year-old male is also shown to highlight the role of neurovascular compression and the importance of using MR angiography to evaluate cases presenting clinically with ophthalmoplegic migraine.

Analysis of Early Neuroimaging Results in Patients with Acute Isolated Ocular Motor Nerve Palsy

Purpose: To evaluate the efficacy of early neuroimaging in patients with acute isolated 3rd, 4th, and 6th nerve palsy.Methods: Neuroimaging tests were performed in patients >50 years old with acute isolated 3rd, 4th, and 6th nerve palsy. The frequencies and types of abnormal findings were evaluated. All patients were divided into ischemic and non-ischemic groups and differences in clinical characteristics between groups were analyzed.Results: Of the 55 patients, nine (16.4%) had abnormal findings on brain imaging. Among 26 patients with 6th nerve palsy, four (15.4%) were found to have a cause including brain tumor, cerebrovascular compression, carotid cavernous fistula. Superior oblique muscle atrophy was found in two of 19 patients (10.5%) with 4th nerve palsy. Three of 10 patients (30%) with 3rd nerve palsy had abnormal findings and there were cases of pituitary apoplexy, posterior communicating, and cerebrovascular compression.Conclusions: In patients with acute isolated oculomotor paralysis, early neuroimaging tests play an important role in differential diagnosis and evaluation of causes that may lead to mortality.

Microvascular Decompression for Oculomotor Nerve Palsy due to Nonaneurysmal Vascular Compression

BACKGROUND

Diabetes mellitus and aneurysmal compression are well-known causes of oculomotor nerve palsy (ONP), but nonaneurysmal vascular compression of the oculomotor nerve has rarely been reported.

CASE DESCRIPTION

A 70-year-old nondiabetic man presented with left ONP for the past 2 days. Magnetic resonance imaging revealed the left posterior communicating artery to be compressing the left oculomotor nerve. Microvascular decompression of the offending artery from the nerve via a left frontotemporal craniotomy was performed; the nerve showed a color change suggestive of degenerative alteration. ONP was fully resolved within 1 month of surgery.

CONCLUSIONS

Whether nonaneurysmal vascular compression of the oculomotor nerve is a true cause of ONP is sometimes controversial. However, recent developments in magnetic resonance imaging can clearly demonstrate the spatial relationship between the oculomotor nerve and vessels. Detailed magnetic resonance imaging should be used to diagnose compression of the oculomotor nerve by blood vessels. Microvascular decompression is the treatment of choice in this situation.

The oculomotor neurovascular conflict: Literature review and proposal of management

BACKGROUND

The Oculomotor nerve (OCN) lies in a close relationship with large arteries inside the basal cisterns. Therefore, it may be compressed by vascular malformations or aneurysms. Nevertheless, the compression is not always related to pathologic conditions. Indeed, some cases of neurovascular conflicts of the OCN have been described in the literature.

METHODS

A case of neurovascular conflict of the OCN resolved after steroid treatment is reported. Additionally, a systematic literature review of those cases was performed.

RESULTS

OCN palsy due to a neurovascular conflict has been described as acute or chronic persistent palsy, or with an intermittent presentation. Symptoms result from compression, although asymptomatic compression is not uncommon. Surgical treatment, pharmacological treatment, and observation have been reported as options in the literature. Microvascular decompression was employed effectively in some cases of OCN neurovascular conflict. Nevertheless, other cases were treated successfully with steroids (persistent presentation) and carbamazepine (intermittent presentation). A management algorithm based on the results of the literature review is proposed.

CONCLUSIONS

Treatment options for OCN neurovascular conflicts and their results are heterogeneous. Based on the literature review, the pharmacological treatment seems to be the most appropriate first-line approach, reserving surgery for refractory cases. Collecting clinical information about new cases will allow defining treatment standards for this rare condition.

Is fetal-type posterior cerebral artery a risk factor for intracranial aneurysm as analyzed by multislice CT angiography?

Fetal-type posterior cerebral artery (FTP) is a common anatomic variation that is closely associated with intracranial aneurysm. In the present study, multislice computed tomography angiography (CTA) was performed to assess whether FTP is a risk factor for intracranial aneurysm. CTA data of 364 consecutive cases of patients who were suspected with cerebrovascular disease or intracranial aneurysm of intracranial artery from 2013 to 2016 were reviewed and the incidence rates of FTP, other variations of the circle of Willis, intracranial aneurysm and FTP with intracranial aneurysm were evaluated. The χ² test was used to assess the influence of FTP and gender on the incidence rates of other variations of the circle of Willis, intracranial aneurysm and internal carotid artery-posterior communicating artery (ICA-PComA) aneurysm. Binary logistic regression analysis was performed to assess the associations of FTP and gender with intracranial aneurysm and ICA-PComA aneurysm. Compared with non-FTP patients, FTP cases exhibited significantly higher rates of other variations of the circle of Willis (χ²=80.173, P<0.001) and ICA-PComA aneurysm (χ²=4.437, P=0.035). Among patients with FTP and bilateral FTP, more female than male patients with intracranial aneurysm were identified. However, among all patients with intracranial aneurysm, no statistically significant differences in the prevalence of FTP (χ²=2.577, P=0.108) and bilateral FTP (χ²=2.199, P=0.159) between males and females were identified. Binary logistic regression analysis revealed that FTP and gender were risk factors for intracranial aneurysm and ICA-PComA aneurysm. A moderate association between FTP and ICA-PComA aneurysm (OR=2.762) were identified, although there was a weak association between FTP and intracranial aneurysm [odds ratio (OR)=1.365]. Furthermore, a strong association was identified between gender and intracranial aneurysm (OR=0.328), and a moderate association existed between gender and ICA-PComA aneurysm (OR=0.357). In conclusion, female gender is an independent risk factor for intracranial aneurysm, and FTP and female gender are independent risk factors for ICA-PComA aneurysm.

Monocular diplopia-associated migraine-like headache induced by nicotine withdrawal

We describe an extremely rare case of migraine‐associated monocular diplopia developed in a 23‐year‐old man after sudden cessation of smoking. The physical examination and brain MRI scan were unremarkable. The symptoms resolved after starting nicotine patch. We reviewed the literature and discussed the diagnosis and possible mechanism of this phenomenon.

Oculomotor nerve palsy secondary to aberrant posterior cerebral artery

The authors report a rare case of an oculomotor nerve palsy attributed to mass effect from an aberrant posterior cerebral artery. The patient presented with complete ptosis, mydriasis and ophthalmoplegia of the affected eye. MRI demonstrated distortion of the oculomotor nerve as it traversed inferior to the non-aneurysmal P1 segment of an aberrant posterior cerebral artery. The oculomotor nerve palsy resolved spontaneously.