Tolosa-Hunt症候群と内頚―後交通動脈分岐部未破裂動脈瘤による同側動眼神経麻痺を同時発症した1例

Simultaneous Presentation of Tolosa-Hunt Syndrome and Oculomotor Nerve Palsy due to the Nonruptured Internal Carotid-Posterior Communicating Artery Aneurysm: A Case Report

Ⅰ．はじめに

　Tolosa-Hunt症候群は多くが片側V_Ⅰ領域，あるいはV_Ⅱ領域も含む顔面痛に神経原性の同側眼筋運動障害，瞳孔括約筋調節障害がさまざまな組み合わせで合併した臨床徴候である^1,4)．ステロイドに反応良好な再発性の海綿静脈洞ないし上眼窩裂に存在する非特異的炎症性肉芽腫病変と関連付けて論じられることが多いが，原因疾患は多岐にわたり，画像上特異所見を欠く場合には診断に苦慮することも多い^1,4)．動眼神経麻痺は後交通動脈瘤との関連でしばしば述べられる一方で，脳動脈瘤圧迫の様式から動眼神経障害を分類化したものは存在しない^5,6)．今回われわれは，Tolosa-Hunt症候群と時期を同じくして動眼神経麻痺が出現，同側内頚－後交通動脈分岐部未破裂動脈瘤が考えられた症例を経験したので報告する．

　A 45-year-old female developed mild dysesthesia and swelling, followed by ptosis and trigeminal pain, in the right side of the face. Her past medical history was unremarkable, and she had not been aware of any infectious sign. A local otolaryngologist administered glucocorticoid therapy that resolved the face pain, but the ptosis persisted. Neurological examination found complete right oculomotor nerve paresis and mild sensory loss in the first and second segments of the right trigeminal nerve. Blood examination found no abnormalities. Neuroimaging revealed a saccular aneurysm at the branching site of the posterior communicating artery, projecting posteriorly and adjacent to the dorsum sellae, without other intracranial abnormalities. Cerebral angiography demonstrated poor opacification of the superior ophthalmic vein and cavernous sinus on the right side. The patient underwent coil embolization under a diagnosis of symptomatic aneurysm, but her oculomotor neuropathy was only partially improved. We thought that the impairment of the oculomotor function by inflammatory reaction in the cavernous sinus and mechanical compression by the aneurysm had already persisted for too long for post-treatment recovery. We think that the simultaneous occurrence of Tolosa-Hunt syndrome and oculomotor nerve palsy may have resulted because trigeminal neuralgia had increased the blood pressure to induce rapid growth of the preexisting aneurysm, or the inflammatory reaction in the cavernous sinus had promoted the growth of the aneurysm, or that the association was by chance.