Issue: Vojnosanit Pregl 2017; Vol. 74 (No. 12)
To wait for a spontaneous recovery of the third cranial nerve palsy occurring after the coiling of a PComA aneurysm or to implement surgical treatment? – A case report.
Authors:
Miodrag Peulić, Vojin Kovačević, Marina Miletić Kovačević, Danica Grujičić
Introduction. In the last two decades a method of endovascularembolization has been imposed as a method of choice in the treatment
of unruptured intracranial aneurysms. Therefore, the problem
of treating posterior communicating artery (PComA) aneurysms presenting
with the third cranial nerve (TCN) palsy has become even
more complex. The case of a patient reported in the paper itself has
presented a dilemma of whether to wait for spontaneous resolution
of ophthalmoplegia developed after the coiling of a PComA aneurysm
or whether to implement an early surgical treatment. Case report.
An unruptured saccular aneurysm, directed inferolaterally in
the right internal carotid artery (ICA) segment in the position of the
PcomA origin, was diagnosed in a 58-year-old male patient. The aneurysm
was measuring 9 mm in diameter while the neck was measuring
5 mm. The day before the planned embolization, the patient
developed ipsilateral ophthalmoparesis, whereas the first day after
the endovascular procedure was completed, the patient developed
right-sided complete ophthalmoplegia. Ten weeks after the endovascular
embolization our team decided to perform a microsurgical
treatment including aneurysm clipping and coil extraction. Eighteen
months after the surgery, the patient made a full recovery of the
functions of musculus (m) levator palpabrae, m. rectus medialis and pupillary
function, with a partial recovery of the functions of m. obliqus inferior,
m. rectus inferior and m. rectus superior. Conclusion. According to medical
research and literature, the partial recovery of the TCN palsy is
expected to happen in the first few weeks after embolization. Despite
the completion of endovascular treatment progression of ophthalmoparesis
to ophthalmoplegia without any simptoms of clinical
improvement after 10 weeks is considered to be an indicator of longstanding
TCN compression, which can lead to irreversible nerve
damage. Despite the increase in the use of an endovascular embolization
method in the treatment of PComA aneurysms preceeded by
the TCN palsy, neurosurgical treatment is believed to have been
necessary. Still, there is one question left to be answered - did we react
too late in this particular case?
