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-Axial magnetic resonance angiogram with contrast and 3D TOF image demonstrating saccular aneurysm (blue arrow) in the distal left internal carotid artery at lateral part of cavernous sinus (color version of figure is available online.)
Source publication
The oculomotor nerve palsy is a rare neurological deficit, it is associated with numerous underlying pathologies. Including stroke, neoplasms, trauma, post-surgical inflammation, and microvascular damage from chronic disease. It can cause a set of neurological deficits, including diplopia from oculomotor nerve involvement, decreased visual acuity f...
Context in source publication
Context 1
... MRI and MRA were performed few hours after unremarkable CT brain for stroke ( Fig. 1 ) and it obtained in conventional sequences plus 3D FIESTA sequence with reformatting which revealed no evidence of acute stroke or restriction of diffusion however, ( Fig. 3 ) there is a signal void structure, compressing the left oculomotor nerve after passing through left chiasmatic cistern and upon entrance to cavernous sinus. Reformatted images demonstrate that this structure arising from distal left internal carotid artery at lateral part of cavernous sinus likely represents a saccular aneurysm which is confirmed by Magnetic resonance angiography (MRA) ( Fig. 2 ). It is measured 7.6 × 6 × 7 mm Our patient was diagnosed in our institution then she was referred to a tertiary referral hospital for further appropriate management. ...
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Citations
... In fact, 2 of the most common causes of non-pupil-sparing oculomotor nerve palsy are posterior communicating artery aneurysms and distal basilar artery aneurysms (20). Less commonly, aneurysms of the cavernous portion of the ICA have been reported to cause third cranial nerve palsy (21). Although the pathophysiology behind oculomotor nerve palsy is thought to be due to pulsatility and compressive mass effect of large aneurysms, there are reports of small aneurysms causing third cranial nerve palsy, refuting the idea that these deficits are strictly related to aneurysm size (21)(22)(23). ...
... Less commonly, aneurysms of the cavernous portion of the ICA have been reported to cause third cranial nerve palsy (21). Although the pathophysiology behind oculomotor nerve palsy is thought to be due to pulsatility and compressive mass effect of large aneurysms, there are reports of small aneurysms causing third cranial nerve palsy, refuting the idea that these deficits are strictly related to aneurysm size (21)(22)(23). Any aneurysm of the circle of Willis can cause anterior optic pathway compression and result in visual deficits; however, the most common locations include the ICA, specifically the paraclinoid region. ...
Background
Approximately 3.2%–6% of the general population harbor an unruptured intracranial aneurysm (UIA). Ruptured aneurysms represent a significant healthcare burden, and preventing rupture relies on early detection and treatment. Most patients with UIAs are asymptomatic, and many of the symptoms associated with UIAs are nonspecific, which makes diagnosis challenging. This study explored symptoms associated with UIAs, the rate of resolution of such symptoms after microsurgical treatment, and the likely pathophysiology.
Methods
A retrospective review of patients with UIAs who underwent microsurgical treatment from January 1, 2014, to December 31, 2020, at a single quaternary center were identified. Analyses included the prevalence of nonspecific symptoms upon clinical presentation and postoperative follow-up; comparisons of symptomatology by aneurysmal location; and comparisons of patient demographics, aneurysmal characteristics, and poor neurologic outcome at postoperative follow-up stratified by symptomatic versus asymptomatic presentation.
Results
The analysis included 454 patients; 350 (77%) were symptomatic. The most common presenting symptom among all 454 patients was headache (n = 211 [46%]), followed by vertigo (n = 94 [21%]), cognitive disturbance (n = 68[15%]), and visual disturbance (n = 64 [14%]). Among 328 patients assessed for postoperative symptoms, 258 (79%) experienced symptom resolution or improvement.
Conclusion
This cohort demonstrates that the clinical presentation of patients with UIAs can be associated with vague and nonspecific symptoms. Early detection is crucial to prevent aneurysmal subarachnoid hemorrhage. It is imperative that physicians not rule out aneurysms in the setting of nonspecific neurologic symptoms.
... A specific type of aneurysms with which CISS-imaging can be especially useful is represented by internal carotid artery (ICA) aneurysms, located in the cavernous sinus (cavernous carotid aneurysms). These aneurysms, when symptomatic, can cause various neurological deficits, due to compression of the surrounding cranial nerves passing through the cavernous sinus itself (the abducens nerve) or its lateral walls (the oculomotor nerve, trochlear nerve, and ophthalmic and maxillary branches of the trigeminal nerve) [47]. As previously discussed, 3D CISS imaging is considered the main diagnostic tool to study cranial nerve segments and their relationships with surrounding structures. ...
... (cavernous carotid aneurysms). These aneurysms, when symptomatic, can cause various neurological deficits, due to compression of the surrounding cranial nerves passing through the cavernous sinus itself (the abducens nerve) or its lateral walls (the oculomotor nerve, trochlear nerve, and ophthalmic and maxillary branches of the trigeminal nerve) [47]. As previously discussed, 3D CISS imaging is considered the main diagnostic tool to study cranial nerve segments and their relationships with surrounding structures. ...
Three-dimensional constructive interference in steady state (3D CISS) is a steady-state gradient-echo sequence in magnetic resonance imaging (MRI) that has been used in an increasing number of applications in the study of brain disease in recent years. Owing to the very high spatial resolution, the strong hyperintensity of the cerebrospinal fluid signal and the high contrast-to-noise ratio, 3D CISS can be employed in a wide range of scenarios, ranging from the traditional study of cranial nerves, the ventricular system, the subarachnoid cisterns and related pathology to more recently discussed applications, such as the fundamental role it can assume in the setting of acute ischemic stroke, vascular malformations, infections and several brain tumors. In this review, after briefly summarizing its fundamental physical principles, we examine in detail the various applications of 3D CISS in brain imaging, providing numerous representative cases, so as to help radiologists improve its use in imaging protocols in daily clinical practice.
... A non-pupil-sparing oculomotor nerve palsy prompt an urgent radiological investigation [8]. MRA or CT angiography must be performed urgently to exclude an aneurysm [9,10]. ...
... Clinical manifestation include complete ptosis and eyeball in the 'down and out' position [11]. However, if the oculomotor nerve palsy involved the pupil, further investigation with CTA or MRA should be performed in order to rule out compression from the probable aneurysm originating from the internal carotid and posterior communicating artery [9,10]. Compression along the parasympathetic pupillary fibres will cause the pupil size to be dilated [5]. ...
Background: The coulometer or the third cranial nerve gives innervation to the four of the six extraocular muscles, namely the medial rectus, superior rectus, inferior rectus, inferior oblique. This cranial nerve is responsible for the upward and downward as well as adduction movement of the eyeball. It also retract the upper eyelid by innervating the levator palpebrae superioris muscle.Oculomotor nerve regulates the pupillary constriction via the parasympathetic nervous system. Oculomotor nerve palsy may affect any of these roles depending from its aetiology. Case presentation: We are reporting a case of complete right sided oculomotor nerve palsy secondary to carotid cavernous fistulain a poorly controlled diabetic patient. This patient had a complete right sided ptosis with the eyeball deviated to the 'down and out' position in keeping with dilated pupil. A magnetic resonance angiography had confirmed the diagnosis of carotidcavernous fistula of which an urgent embolization procedure was performed. Conclusions: Diagnosing an oculomotor cranial nerve palsy correctly and to determine its exact etiology is vital. A complete, pupil-involving oculomotor nerve palsy warrants an urgent radiological imaging as to accurately localized the lesion that give rise to the presenting symptoms.
