Isolated oculomotor nerve palsy inspontaneous internal carotid artery dissection: case report

Abstract

-Partial oculosympathetic palsy followed by ischemic manifestations in brain or retina are the main symptoms of extracranial internal carotid artery (ICA) dissection. Unusually, cranial nerves may be affected. Isolated oculomotor nerve palsy is found only rarely. Case: We present a 50-year-old nondiabetic man who experienced acute onset of right occipital headache which spread to the right retro-orbital region. Five days later he noticed diplopia and right blurred vision sensation. Neurologic examination disclosed only impaired adduction and upward gaze of right eye, slight ipsilateral pupillary dilatation, without ptosis. Brain MRI was normal. Angiography showed right internal carotid artery dissection with forward occlusion to the base of the skull. Intravenous heparin followed by warfarin was prescribed. The headache and the oculomotor nerve deficit gradually resolved in the next three weeks. Discussion: Isolated oculomotor nerve palsy is underrecognized as a clinical presentation of extracranial ICA dissection. If the angiographic evaluation is incomplete without careful study of extracranial arteries, misdiagnosis may lead to failure to initiate early treatment to prevent thromboembolic complications. For this reason we draw attention to the need for careful evaluation of cervical arteries in patients with oculomotor nerve palsy. Mechanical compression or stretching of the third nerve are possible mechanisms, but the direct impairment of the blood supply to the third nerve seems to be the most plausible explanation.KEY WORDS: third nerve; oculomotor palsy; carotid artery; dissection; angiography. Paralisia isolada do nervo oculomotor na dissecção de artéria carótida interna: relato de casoRESUMO -A paralisia oculosimpática parcial (síndrome de Horner) seguida por manifestações isquêmicas cerebrais ou retinianas são os principais sintomas da dissecção da artéria carótida interna (ACI) extracraniana. O acometimento de nervos cranianos é incomum. Apenas raramente a paralisia isolada do nervo oculomotor pode ser encontrada. Caso: homem de 50 anos, sem diabetes, apresentou cefaléia occipital de início súbito irradiada a seguir para a região retro-orbitária direita. Após 5 dias começou a notar diplopia e visão embassada no olho direito, quando procurou o hospital. O exame neurológico evidenciou apenas prejuízo da adução e do olhar vertical para cima no olho direito, com discreta dilatação pupilar ipsilateral, sem ptose. RNM foi normal. A angiografia digital revelou dissecção da ACI direita com oclusão a montante até a base do crânio. A anticoagulação foi iniciada. A cefaléia e a movimentação ocular melhoraram em 3 semanas. Discussão: A paralisia isolada do nervo oculomotor dificilmente é reconhecida como um possível sinal clínico de dissecção da ACI. Se o estudo angiográfico for incompleto, sem a avaliação cuidadosa das artérias extracranianas, esse diagnóstico deixa de ser feito, impedindo assim o início precoce da anticoagulação para a prevenção dos eventos tromboembólicos. Por isso, reforçamos a impor...

Anisocoric pupil generated by azygos anterior cerebral artery: a case report

“…According to previous descriptions (CAMPOS, MASSARO and SCAFF, 2003), pupillary involvement is not a rule, but in some cases mydriasis may be the only manifestation for the few days preceding the complete oculomotor nerve palsy. In other patients the pupil tends to be miotic, presumably because of the concurrent oculosympathetic palsy due to the pericarotid sympathetic plexus involvement.…”

Complete ophthalmoplegia, complete ptosis and dilated pupil due to internal carotid artery dissection: as the first manifestation of Takayasu arteritis

“…Campos, C.R., et al, reported a 50-year-old non-diabetic man who experienced acute onset right sided headache, impaired adduction and upward gaze of right eye and slight ipsilateral pupillary dilatation without ptosis. His angiography showed right ICA dissection with forward occlusion to the base of the skull [11]. …”

Double or nothing: red flag symptoms of critical carotid stenosis, a case report

“…Posteriorly, posterior cerebral and cavernous portion of internal carotid branches, give rise other vessels for the network [2]. This pattern of blood supply, coming from different arterial territories, could explain why oculomotor palsy is very uncommon, even transiently, after carotid occlussions or carotid ligation during treatment of aneruysms [4] since occlusion of several components of the nerves nutrient supply is probably required to produce significant ischemia [6–8]. …”

“…But, in the past few years, several clinical cases of binocular diplopia caused by oculomotor nerve palsies have been described associated with stenosis or occlusion of the ICA [2, 3]. The majority of these cases have been reported on young patients with arterial dissection and few cases in patients after radiation induced atherosclerosis [4, 5]. …”