- Department of Neurological Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan.
Satoshi Tsutsumi, Department of Neurological Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan.
DOI:10.25259/SNI_364_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Hiroki Sugiyama, Satoshi Tsutsumi, Hisato Ishii. Oculomotor nerve palsy presumably caused by cisternal drain during microsurgical clipping. 02-Sep-2022;13:398
How to cite this URL: Hiroki Sugiyama, Satoshi Tsutsumi, Hisato Ishii. Oculomotor nerve palsy presumably caused by cisternal drain during microsurgical clipping. 02-Sep-2022;13:398. Available from: https://surgicalneurologyint.com/surgicalint-articles/11844/
Background: Oculomotor nerve palsy can be caused by diverse etiologies, but no report has yet documented its association with a cisternal drain.
Case Description: A 35-year-old woman presented with severe headache. The patient did not exhibit oculomotor nerve palsy at presentation. Cranial computed tomography (CT) revealed diffuse subarachnoid hemorrhage. The patient underwent open microsurgical clipping of a ruptured middle cerebral artery aneurysm. During surgery, a cisternal drain was placed in the basal cistern at the medial aspect of the clinoidal portion of the internal carotid artery. The patient presented with the left oculomotor nerve palsy immediately after surgery. CT revealed displacement of the cisternal drain to the lateral aspect of the anterior clinoid process. The patient’s mydriasis and sluggish light reaction recovered after 7 days, while extraocular movements persisted for 50 days. The constructive interference steady-state sequence detected the left oculomotor nerve coursing adjacent to the clinoidal internal carotid artery.
Conclusion: Oculomotor nerve palsy can be caused by collision with a thin silastic tube placed during surgery for aneurysmal subarachnoid hemorrhage. Withdrawal of the drain as early as possible is recommended when drain-associated oculomotor nerve palsy is suspected.
Keywords: Cisternal drain, Compressive neuropathy, Functional outcome, Oculomotor nerve palsy
Cisternal drainage is a common neurosurgical procedure performed during microsurgical clipping of an aneurysmal subarachnoid hemorrhage, with the aim of continuous removal of subarachnoid clots lodged in the basal cistern.[
The oculomotor nerve, the third cranial nerve, initially arises from the medial aspect of the cerebral peduncle at the midbrain level. This then courses forward in the interpeduncular fossa and basal cistern, passes through the oculomotor triangle, and courses in the cavernous sinus. The nerve, then, passes through the central superior orbital fissure and enters the orbit.[
Here, we report a unique case of oculomotor nerve palsy, presumably caused by compression of a cisternal drain placed during surgery for aneurysmal subarachnoid hemorrhage.
A 35-year-old, previously healthy woman, presented with severe headache and was transferred to the hospital. At presentation, the patient was drowsy, but did not show any focal neurological deficits. Her ocular position was neutral on both sides, and she presented with isochoric pupils. Ptosis was not found. Cranial computed tomography (CT) revealed a diffuse subarachnoid hemorrhage with a subtle ventriculomegaly. No abnormal findings were observed in the midbrain [
Intraoperative photo showing a cisternal drain (arrows), placed with the tip at the medial aspect of the internal carotid artery and anterior clinoid process following application of a clip (arrowhead) to the neck of the middle cerebral artery aneurysm. D: Dura mater, FL: frontal lobe, and TL: temporal lobe. ACP: Anterior clinoid process; IC: Internal carotid artery.
Axial (a and b) and coronal (c and d) computed tomography performed immediately after surgery showing the tip of the cisternal drain (a, c, d, arrows) displaced to the lateral aspect of the anterior clinoid process (ACP). DS: Dorsum sellae; Arrowhead: A clip applied to the ruptured middle cerebral artery aneurysm; Dashed arrow: ventricular catheter.
(a and b) Adjacent images of the axial constructive interference steady-state sequence performed on postoperative day 30, showing the cisternal portion of the left oculomotor nerve (III) coursing adjacent to the lateral wall of the clinoidal internal carotid artery (IC). ACP: Anterior clinoid process.
(a-d) Serial images of the coronal constructive interference steady-state sequence performed on postoperative day 30, showing the cisternal portion of the left oculomotor nerve (III) coursing adjacent to the lateral wall of the clinoidal internal carotid artery (IC). a (anterior)→ d (posterior).
In the present patient, oculomotor nerve palsy was initially not found, but developed on the ipsilateral side immediately after surgery. CT performed immediately after surgery showed displacement of the tip of the cisternal drain, initially placed to the medial aspect of the anterior clinoid process, to the lateral aspect. No other significant CT findings associated with oculomotor nerve palsy were found. Furthermore, on the CISS sequence, the cisternal portion of the left oculomotor nerve was found to course adjacent to the lateral wall of the clinoidal internal carotid artery. Therefore, we assumed that the oculomotor nerve palsy was caused by collision with the displaced cisternal drain. Displacement of the drain probably occurred when releasing the retraction to the left frontal lobe at the final stage of the microsurgery, combined with the tight intracranial cavity of a young patient sustaining subarachnoid hemorrhage.
Few reports have documented cases of traumatic oculomotor nerve palsy.[
Cisternal drainage is a common neurosurgical procedure performed during microsurgical clipping of an aneurysmal subarachnoid hemorrhage but can cause neurovascular complications.[
Oculomotor nerve palsy can be caused by collision with a thin silastic tube placed during surgery for aneurysmal subarachnoid hemorrhage. Withdrawal of the drain as early as possible is recommended when drain-associated oculomotor nerve palsy is suspected.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
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