Ophthalmology Clinics and Research (ISSN:2638-115X)
Case Report
A Rare Causatum of Aneurysm Surgery
Mahesh Kumar*, Vidhi Shah, Prithviraj Udaya and Kowsalya Akkayasamy
Corresponding Author: Mahesh Kumar, Department Of Neuro- Ophthalmology, Aravind Eye Hospital, Madurai, India
Received: June 12, 2019; Revised: December 05, 2019; Accepted: June 17, 2019
Citation: Kumar M, Shah V, Udaya P & Akkayasamy K. (2019) A Rare Causatum of Aneurysm Surgery. Ophthalmol Clin Res, 2(3): 89-91.
Copyrights: ©2019 Kumar M, Shah V, Udaya P & Akkayasamy K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Oculomotor nerve palsies (ONP) are commonly observed in lieu of intracranial aneurysms or subsequent to aneurysm surgeries. A 31 year old gentleman with no neurological deficits prior to an aneurysm surgery done 5 months ago, presented with drooping of the right upper lid. Preoperative neuroimaging had revealed a basilar artery tip aneurysm with mild vasospasm of P1 segment of the right posterior cerebral artery. Examination of right eye revealed a complete ptosis with a mid-dilated non-reacting pupil and limitation of elevation, depression and adduction. He also exhibited left hemiparesis and weakness of left half of the face with forehead spared. The myriad of features is plausibly due to an “exaggerated vasospasm” of the thalamo perforators compromising the blood supply to the cerebral peduncle.We report a rare case of oculomotor nerve palsy with concomitant brainstem involvement post aneurysm surgery.


Keywords: Distal basilar artery aneurysm, Post aneurysm surgery, Hemiparesis, Facial palsy, Oculomotor nerve palsy

INTRODUCTION

Oculomotor nerve palsies (ONP) are commonly observed in lieu of intracranial aneurysms or subsequent to aneurysm surgeries. We report a rare case of a third nerve palsy in conjunction with a contralateral seventh nerve palsy and hemiparesis in a young man post aneurysm surgery.


CASE REPORT


A 31-year-old gentleman with hemorrhoids since childhood was rushed to the emergency room five months ago with intense headache and an episode of hematemesis. Ultrasonography of the abdomen was normal. Neuroimaging (Figure 1) had revealed a basilar artery tip aneurysm with “mild vasospasm” of P1 segment of the right posterior cerebral artery. A week later, an inadvertent intraoperative aneurysm rupture had necessitated the use of “forced” temporary clipping. Consequently, he was ventilator- dependent in the immediate postoperative period. On regaining consciousness, he reported inability to open the right eye, asymmetry of the mouth with weakness of the left arm and leg.

Currently, his best corrected visual acuity was 20/40, right  eye and 20/20, left eye. A bony depression noted in the right fronto-parietal region corresponded to the site of surgery. There was complete ptosis of the right upper lid (Figure 2) and 15 degrees exotropia in primary gaze with limitation of elevation, depression and adduction (Figure 3). The  pupil was mid-dilated and fixed. Features suggestive of  a  left upper motor neuron (UMN) facial palsy were, preserved forehead creases (Figure 2), weakness of the  orbicularis  oculi and buccinator with minimal lagophthalmos in addition to the angle of the mouth deviated to the right (Figure 4). Remaining cranial nerves were intact. Diplopia and Hess charting verified a right third nerve palsy. An observation of right complete pupil involving ONP with left UMN facial palsy and left hemiparesis, status post basilar  artery  aneurysm clipping was made.

DISCUSSION
Basilar artery (BA) aneurysms account for 3-8% of intracranial aneurysms [1] and are the most common aneurysms in the posterior fossa [2]. The incidence of ONP post BA aneurysm clipping is estimated to be 25-80% [3-7] the risk factors [3,4,8,9] being: 1) Large aneurysms  (>10  mm) 2) Younger age 3) Poor Hunt and Hess grade 4) Temporary arterial occlusion 5)  Poor  Glasgow  outcome scale score 6) Posterior projection of distal aneurysm. In accordance with the risk factors, younger age and temporary clipping predisposed our patient to ONP following surgery; however he also exhibited contralateral facial weakness and hemiparesis. Exhaustive literature search divulged two reports, one by Cruciger et al. [5] who stated 29% cases developing ONP with hemiparesis post BA  aneurysm  surgery and one case of superior Foville syndrome after clipping of basilar bifurcation aneurysm [10]. Therefore, the concurrent involvement of oculomotor nerve, facial  nerve  and corticospinal tract post aneurysm surgery is unusual.

The possible mechanism for the course of events could be intraoperative vasospasm [6,11,12],  mechanical  damage [3,4] or vascular injury [5] attributable to the narrow surgical corridor in younger patients, increasing the manipulation of the surrounding neurovascular structures [5,6]. In our case, “exaggerated vasospasm” is plausibly the cause, augmenting  a pre-existent “mild vasospasm” of the P1 segment of posterior cerebral artery (thalamo perforators) in the absence of any neurological deficits.  The  “exaggerated  vasospasm” in the midst of surgery, brought on by temporary clipping for an inadvertent aneurysm rupture, probably critically compromised the blood supply to the cerebral peduncle resulting in ischemia of the oculomotor nerve, corticobulbar and corticospinal tracts that caused the myriad of features. However, the definitive cause could not be ascertained as ventilator-dependency is a relative contraindication for CT angiography.

Numerous studies [3,5,6] have reported excellent recovery rates for isolated ONPs, with complete recovery occurring within 3 to 6 months. However, the recovery in our patient was incomplete due to  a  concomitant  brainstem involvement.

To summarise, encountering ONPs post aneurysm  surgeries is common, albeit the recovery is incomplete when multiple cranial nerves are affected. The parallelism between hemorrhoids and basilar artery aneurysm in our case was significative of an inherent vessel wall weakness [13]. It is highly recommended to screen patients with hemorrhoids for aneurysms elsewhere.

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4.       Horikoshi T, Nukui H, Yagishita T, Nishigaya K, Fukasawa I, et al. (1999) Oculomotor nerve palsy after surgery for upper basilar  artery  aneurysms. Neurosurgery 44: 705-710.


5.       Cruciger MP, Hoyt WF, Wilson CB (1981) Peripheral and midbrain oculomotor palsies from operations for basilar bifurcation aneurysm in a series of 31  cases.  Surg Neurol 15: 215-216.


6.       Sharma M, Ahmed O, Ambekar S, Sonig A, Nanda A (2014) Factors predicting the oculomotor nerve palsy following surgical clipping of distal vertebrobasilar aneurysms: A single-institution experience. J Neurol  Surg B Skull Base 75: 261-267.

7.       Redekop GJ, Durity FA, Woodhurst WB (1997) Management-related morbidity in unselected aneurysms of the upper basilar artery. J Neurosurg 87: 836-842.

8.       Lozier AP, Kim GH, Sciacca RR, Connolly ES Jr, Solomon RA (2004) Microsurgical treatment of basilar apex aneurysms: Perioperative and long-term clinical outcome. Neurosurgery 54: 286-296.

9.       Samson D, Batjer HH, Kopitnik TA Jr (1999) Current results of the surgical management of aneurysms of the basilar apex. Neurosurgery 44: 697-702.

10.    Takase M, Saeki N, Oka N, Satoh A, Otaki M, et al. (1981) Superior Foville syndrome after clipping of  basilar bifurcation aneurysm - Case report (author's transl). No Shinkei Geka 9: 343-347.

11.    Goto K, Imai H, Nakazato O, Tsuda T, Okajima T  (1993) Inferior branch palsy of the oculomotor nerve following clipping of basilar apex aneurysm. Rinsho Shinkeigaku 33: 203-206.

12.    Kudo T (1986) Postoperative oculomotor palsy due to vasospasm in a patient with a ruptured internal carotid artery aneurysm: A case report. Neurosurgery 19: 274- 277.

13.    Miller NR, Newman NJ (1998) Aneurysms. In: Walsh and Hoyt’s clinical neuroophthalmology. 5th Edn. Baltimore: Williams & Wilkins.

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