- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA
- Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA
- Department of Neurosurgery, Gates Vascular Institute–Kaleida Health, New York, USA
- Department of Neurology, Gates Vascular Institute–Kaleida Health, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
Adnan H. Siddiqui
Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA
Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA
Department of Neurosurgery, Gates Vascular Institute–Kaleida Health, New York, USA
Jacobs Institute, Buffalo, New York, USA
DOI:10.4103/2152-7806.145653Copyright: © 2014 Kogan M. 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.
How to cite this article: Kogan M, Natarajan SK, Kim N, Sawyer RN, Snyder KV, Siddiqui AH. Third nerve palsy following carotid artery dissection and posterior cerebral artery thrombectomy: Case report and review of the literature. Surg Neurol Int 28-Nov-2014;5:
How to cite this URL: Kogan M, Natarajan SK, Kim N, Sawyer RN, Snyder KV, Siddiqui AH. Third nerve palsy following carotid artery dissection and posterior cerebral artery thrombectomy: Case report and review of the literature. Surg Neurol Int 28-Nov-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/third-nerve-palsy-following-carotid-artery-dissection-posterior-cerebral-artery-thrombectomy-case-report-review-literature/
Background:Common causes of oculomotor nerve palsy are diabetes, aneurysmal compression, and uncal herniation. A lesser-known cause of third nerve dysfunction is ischemia, often due to carotid artery dissection.
Case Description:An 80-year-old man presented with an acute ischemic stroke with a National Institutes of Health Stroke Scale score of >20 from a high cervical internal carotid artery (ICA) dissection and a tandem ICA terminus embolic occlusion with extension of clot into the adjacent fetal posterior cerebral artery (PCA). We used a stentriever to perform selective PCA thrombectomy, with immediate postthrombectomy development of ipsilateral anisocoria. The anisocoria progressed into complete oculomotor nerve palsy over 8 h after the procedure.
Conclusions:The clinical course described in this case is consistent with injury to the third nerve due to mechanical injury or occlusion of perforator supply to the nerve during thrombectomy. Oculomotor nerve palsy is a rare but known complication after ischemia; however, to our knowledge, this is the first case after thrombectomy for a PCA embolus.
Keywords: Carotid artery dissection, mechanical thrombectomy, oculomotor nerve palsy, stroke, third cranial nerve palsy
Common causes of third cranial nerve palsy classically involve medical and compressive (surgical) pathologies. Generally, medical pathologies are at first pupil sparing, whereas compression of the nerve first causes dilation and then subsequent motor dysfunction. In this report, we present a lesser-known cause of third nerve dysfunction due to carotid dissection and discuss the vascular anatomical nuances that need to be considered in the differential of intraprocedural development of oculomotor palsy.
An 80-year-old man with type II diabetes and known atrial fibrillation for which he was on warfarin presented with confusion, aphasia, and right-sided hemiplegia 1.5 h after last seen normal. His level of anticoagulation was subtherapeutic with an international normalized ratio of 1.27. The National Institutes of Health Stroke Scale score was 21 with symmetric pupil reactivity and no gaze deviation. Computed tomography (CT) perfusion imaging suggested a large posterior cerebral artery (PCA) distribution, salvageable penumbra [
(a) Cerebral blood volume scan from a CT perfusion study obtained at the time of admission. A small area of volume deficit is visible in the left PCA territory. (b) Time-to-peak map from the CT perfusion study showing a large area of reduced perfusion in the left PCA, consistent with salvageable penumbra. (c) CT angiogram of the common carotid artery. Proximal occlusion consistent with a dissection flap is seen (arrow). (d) CT angiogram of cerebral vessels showing an early filling defect in the terminal ICA (arrow)
Secondary to severe neurologic dysfunction and inability to cooperate, the patient was emergently intubated and brought to the interventional suite for possible intraarterial thrombectomy. Catheter angiography confirmed cross-flow across the ACOM with an ICA-terminus occlusion. Additionally, the posterior circulation revealed no left P1 segment, confirming a fetal PCA. Left carotid angiography revealed left ICA dissection just distal to the origin of the ICA (flame-shaped ICA stump) and the external carotid artery filling the ophthalmic artery but not the clinoidal segment of the ICA. This suggested the presence of a dissection in the left ICA with an embolus in the ophthalmic, communicating, and terminal segments of the ICA [Figure
Angiograms preceding and following endovascular intervention. (a) Right ICA injection showing contralateral filling of the MCA with a defect suggestive of a dissection in the ICA terminus on the left (arrow). (b) Left vertebral injection showing filling of the right but not the left PCA. There is retrograde filling of the distal left P2 by superior cerebellar artery collaterals (arrow on far right). (c) Left carotid artery angiogram showing progressive narrowing of the ICA lumen (arrow), consistent with artery dissection. (d) Left ICA injection showing late filling of the left ophthalmic artery due to collateral circulation (arrow). No back filling of the ICA terminus was observed. (e) Left ICA injection is shown. The Penumbra catheter (Penumbra, Inc., Alameda, California, USA) visibly cleared the proximal ICA occlusion; however, a dissection flap is visible distally (arrow). (f) Angiogram obtained immediately after Solitaire (ev3-Covidien, Irvine, California, USA) thrombectomy shows good filling of the distal ICA; however, an occlusion persists in the left P2 segment of the PCA (arrow)
Direct aspiration with the 5 Max Aspiration catheter (Penumbra Inc., Alameda, California, USA) resulted in recanalization of the entire ICA with persistent fetal PCA occlusion [
During the 8 h after the thrombectomy procedure, the patient developed a progressive left mydriatic pupil, which ultimately became fixed at 7 mm in diameter to light stimulation [
(a) CT scan of the head on hospital day 1, after left pupillary dilation was first observed. Hypodensity in the left PCA territory is seen; no effacement of cisterns was evident. (b) Axial T2 fluid-attenuated inversion recovery (FLAIR) magnetic resonance image on hospital day 5 showing evolving left PCA infarct. (c) Coronal T2 magnetic resonance image of head. A left-sided hyperintensity is visible in the retroglobar area (arrow), consistent with congestion of the superior ophthalmic vein
Development of an intraprocedural third nerve palsy can be an ominous sign of impending herniation from an enlarging hematoma. In this case, we abandoned further attempts at recanalization to obtain an emergent CT scan to exclude the presence of such a hematoma, resulting potentially in poor outcome from lack of full revascularization. Newer generation angiography systems have the ability to provide close to CT quality images with fluoroscopic equipment,[
The vascular anatomy of the third nerve has been described by Cahill et al.[
The anatomy of the ICA in relation to the third nerve makes it very plausible that a dissection of the cavernous ICA can compromise vascular supply of the distal nerve. Consequently, third, fourth, and sixth nerve palsies are known sequelae of ICA dissection, occurring with a frequency of 2.6%; however, fewer patients develop an isolated third nerve involvement.[
Preganglionic parasympathetic blockade usually occurs in the context of oculomotor nerve palsies, and much has been written about the significance of pupil involvement or pupil “sparing.” In general, if the oculomotor nerve palsy is incomplete, pupil involvement implies an extrinsic compressive lesion until proved otherwise.[
Oculomotor nerve involvement in our patient may have been caused by three factors: Direct irritation (compression) of the oculomotor nerve during thrombectomy, compaction of emboli within the ostia of perforator branches to the third nerve, and extension of the dissection into the cavernous carotid artery after evacuation of the clot. Initial correspondence of the mydriasis to the mechanical removal of the PCA clot argues to a direct mechanical compression of the third nerve. However, because the symptoms waxed and waned and ultimately progressed to a full motor paralysis with ptosis, this explanation alone is less likely. Further, magnetic resonance imaging findings postoperatively did not demonstrate any midbrain stroke to explain the patient's examination findings [Figure
To our knowledge, this is the first report of an isolated third nerve palsy following mechanical thrombectomy of an ICA terminus/PCA embolus. Because of the association between third nerve palsy and uncal herniation from mass effect, this clinical finding warrants an urgent CT scan to exclude a potentially fatal enlarging hematoma. This report highlights nonexpansile causes of oculomotor palsy, which should be considered when faced with this finding during a procedure. We recommend obtaining an emergent intraprocedural fluoroscopic CT-like image to exclude a hematoma prior to abandoning further recanalization in order to acquire a formal CT scan.
The authors thank Paul H. Dressel BFA for assistance with preparation of the illustrations and Debra J. Zimmer for editorial assistance.
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