Neurological Surgery No Shinkei Geka Volume 41, Issue 6 (June 2013)

Rupture of an Internal Carotid-Posterior Communicating Artery Aneurysm Formerly Presented with Transient Pupil-Sparing Oculomotor Nerve Palsy in an Extremely Elderly Patient Toma MIJIN 1 , Keisuke TSUTSUMI 2 , Takashi FUJIMOTO 1 , Hideaki TAKAHATA 2 , Ichiro KAWAHARA 2 , Tomonori ONO 2 , Keisuke TODA 2 , Hiroshi BABA 2 , Masahiro YONEKURA 3 1Residency Program, National Hospital Organization Nagasaki Medical Center 2Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center 3Nagasaki Hospital Agency Keyword: unruptured intracranial aneurysm , internal carotid-posterior communicating artery aneurysm , pupil-sparing oculomotor nerve palsy , warning sign , subarachnoid hemorrhage pp.507-514
Published Date 2013/6/10
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 We recently encountered experienced a rare case of transient pupil-sparing oculomotor nerve palsy(PSONP)caused by an aneurysm at the junction of the internal carotid-and posterior communicating arteries(IC/PC AN)in an 87-year-old, non-diabetic woman.

 She initially presented with diplopia 4 years previously, and was diagnosed, based on incomplete right oculomotor paresis without pupil involvement(PSONP),as external ophthalmoplegia. MR-angiography revealed a long protrusion of the IC/PC AN with posterior-inferior projection, for which she chose to receive conservative management.

 Thirty nine months later, she presented with another transient PSONP. CT angiography(CTA)showed that the aneurysm was enlarged in the posterior-inferior direction. Two days after this last CTA imaging, the aneurysm ruptured with upward enlargement of the bleb. Despite complete external ophthalmoplegia and ptosis, her pupil involvement was still minimal and transient.

 By reviewing reported cases and our own case, we found that a narrow and long aneurysm body and posterior-inferior projection are characteristic for the IC/PC AN that causes PSONP, implying a possible mechanism for PSONP by upward compression of the oculomotor nerve.

 Though rare in its incidence, IC/PC AN could present with PSONP prior to their rupture. Therefore, immediate imaging evaluation in patients presenting with PSONP is essential to prevent devastating rupture events.

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Neurological Surgery 脳神経外科
41巻6号 (2013年6月)
電子版ISSN 1882-1251 印刷版ISSN 0301-2603 医学書院