- Email: [email protected]
Microvascular Decompression for Oculomotor Nerve Palsy: A Case Report and Literature Review
Accepted Manuscript Microvascular Decompression for Oculomotor Nerve Palsy: A Case Report and Literature Review Hussein kheshaifati, MBBS, Faisal Al-Otaibi, MD, Maher Alhejji, MD PII:
S1878-8750(15)01790-8
DOI:
10.1016/j.wneu.2015.12.083
Reference:
WNEU 3583
To appear in:
World Neurosurgery
Received Date: 25 August 2015 Revised Date:
23 December 2015
Accepted Date: 24 December 2015
Please cite this article as: kheshaifati H, Al-Otaibi F, Alhejji M, Microvascular Decompression for Oculomotor Nerve Palsy: A Case Report and Literature Review, World Neurosurgery (2016), doi: 10.1016/j.wneu.2015.12.083. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Microvascular Decompression for Oculomotor Nerve Palsy: A Case Report and Literature Review
a
RI PT
Hussein kheshaifati, MBBSa,✭, Faisal Al-Otaibi, MDb,c, Maher Alhejji, MDa
Department of Neurosurgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
b
✭
Medical School, Lebanese American University
Corresponding author
Hussein kheshaifati, MBBS
M AN U
c
TE D
Prince Sultan Military Medical City, Department of Neurosurgery Riyadh, Saudi Arabia
AC C
EP
Email : [email protected]
SC
Division of Neurosurgery, Neuroscience Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
ACCEPTED MANUSCRIPT
RI PT
Abstract: Introduction: Oculomotor nerve palsy can result as a manifestation of diabetic mellitus or aneurysmal compression. Vascular loop compression is a very rare etiology of
SC
oculomotor nerve palsy. Here we present a case report of microvascular decompression
M AN U
for oculomotor nerve palsy.
Case Report: We present a 16-year-old male, otherwise healthy, who presented with right oculomotor nerve palsy for a period of one year. Aneurysmal compression and intracranial lesion have been ruled out by cerebral angiogram and magnetic resonance imaging (MRI). The presence of vessel loop compression on the nerve was suspected
TE D
based on MRI feature. The patient underwent microvascular decompression via a right subtemporal approach. We intraoperatively confirmed vessel loop compression at the exit zone of the nerve from midbrain. Subsequently, the patient’s oculomotor palsy has
EP
improved gradually over a period of six months.
AC C
Conclusions: Vascular compression of the oculomotor nerve is a very rare finding in neurosurgical practice. A diagnosis of vascular compression is made by excluding other pathologies and utilizing high-resolution images that visualize the nerve and the offending vessel loop. Microvascular decompression can be an effective treatment method for this condition. Keywords: Oculomotor Palsy, Microvascular Decompression
ACCEPTED MANUSCRIPT
Introduction:
RI PT
Microvascular decompression is a well-established procedure for the trigeminal and facial nerves.[9] Vascular compression of the oculomotor nerve is extremely rare, and
only a limited number of isolated case reports have been described in the literature.[11]
The advances in neuroimaging have increased the ability to identify the offending vessel
SC
at the surface of the oculomotor nerve and any associated vascular anomalies.[4] Here we
M AN U
report a case of oculomotor palsy treated with microvascular decompression.
Case Report:
We present a 16-year-old male patient, otherwise healthy, who developed a transient right
TE D
ptosis that occurred before one year. At that time he describe an intermittent episodes of right eyelid drop for few days followed by the complete resolution of these symptoms. Recently, he presented with painful right ptosis associated with diplopia for three weeks’
EP
duration. The patient had no history of major trauma or other neurological symptomatology. His physical examination revealed right oculomotor nerve palsy
AC C
features with ptosis, ophthalmoplegia, and moderate mydriasis. The visual acuity and field was normal. The rest of the neurological examination and the systemic examination was unremarkable. The neurologist suspected a right posterior communicating artery (PCA) aneurysm and referred the patient to neurosurgery service.
ACCEPTED MANUSCRIPT
Magnetic resonance imaging (MRI) and cerebral angiography revealed an anatomical variation of the right PCA in the form of asymmetry in the origin as compared to left side and the presence of trifurcation of the P2 segment (Figure 1). No aneurysm or other
RI PT
structural lesions have been identified. MRI FIESTA (fast imaging employing steady
state acquisition sequence) revealed the PCA loop on the surface of the oculomotor nerve (Figure 2). Based on this result, the diagnosis was made as a vascular loop compressing
SC
the oculomotor nerve.
M AN U
Subsequently the patient underwent microvascular decompression of the oculomotor nerve via a subtemporal surgical approach. A vessel loop of the PCA P2 segment was identified intraoperatively to be compressing the oculomotor nerve at the exit zone from the brainstem after the release of arachnoid membranes. Mobilization of the compressing
TE D
artery segment was done to free the nerve, and a piece of Teflon was placed between the artery and the nerve (Figure 3). The superior cerebellar artery was not causing any compression of the nerve. The patient tolerated surgery well, and the oculomotor palsy
EP
improved slowly and gradually over the subsequent period of three months. Complete resolution of the oculomotor palsy was noted after six months of follow-up with a
AC C
sustained resolution at the last follow-up, which occurred one year after the surgery.
Discussion:
Vascular loop compression is known to be the etiology behind trigeminal and glossopharyngeal neuralgias as well as hemifacial spasm.[2, 3, 5] Oculomotor nerve palsy induced by vascular compression is considered very rare. There are limited case reports
ACCEPTED MANUSCRIPT
in the literature.[1, 7, 8, 10-14] Posterior communicating artery aneurysm is a well-known cause of oculomotor palsy.[6] In contrast, vascular anomalies of PCA and the basilar artery could compress the oculomotor nerve, inducing irritation of the nerve that results
RI PT
in dysfunction and in the clinical manifestation of a non-pupillary sparing oculomotor palsy.[10]
SC
The literature to date only contains three case reports of oculomotor palsy treated with
microvascular decompression.[8, 10, 12] Nakagawa and colleagues reported on a 59-year-
M AN U
old man who presented with vascular compression of the oculomotor nerve on the left side that was treated with microvascular compression.[10] Two months later, the patient presented with right oculomotor palsy due to the same etiology and was likewise treated with microvascular decompression. Suzuki et al. reported a case of a 76-year-old man
TE D
who was operated on for a PCA aneurysm.[12] However, the surgeon did not find any compression of the third nerve by the aneurysm. The surgeon followed the nerve posteriorly and identified a compression of the nerve by both posterior communicating
EP
and superior cerebellar arteries. Another case report described an elderly patient with ocular neuromyotonia due to vascular compression of the oculomotor nerve; this patient
AC C
was treated with microvascular decompression.[8]
Our patient is very young in comparison to the patients described in the literature. The vascular decompression was identified by thin cut MRI and the trifurcation of the PCA was identified by a cerebral angiogram. The patient’s improvement after microvascular decompression was gradual and occurred over a period longer than six months, which
ACCEPTED MANUSCRIPT
was a slow recovery as compared to the rapid improvements described in the literature. We found that a subtemporal approach is optimal for the identification of vascular compression and that this approach was the most commonly used in the previously
RI PT
described case reports.[8, 10, 12]
On the other hand, there are limited case reports for oculomotor nerve vascular
SC
compression without surgical treatment. Hashimoto described a case of a 74-year-old woman with oculomotor palsy due to a tortuous basilar artery identified by a thin cut
M AN U
MRI.[7] Silva and colleagues reported on a patient with bilateral oculomotor nerve palsy caused by vascular compression.[11] Other investigators described unilateral ocular neuromyotonia with oculomotor nerve vascular compression.[13, 14]
TE D
The pathophysiology of oculomotor nerve palsy is likely to be similar to trigeminal neuralgia. Ephaptic neural transmission due to demyelination within a segment of the nerve caused by vascular decompression is so far the most widely accepted hypothesis.
AC C
mechanism.
EP
The improvement after microvascular decompression supports the aforementioned
Conclusion:
Oculomotor nerve palsy can very occasionally be induced by vascular compression. Other etiologies need to be excluded in conjunction with high-resolution thin cut MRI to identify the vascular compression. Microvascular decompression can be considered an effective and safe treatment.
ACCEPTED MANUSCRIPT
Disclosure: The authors have nothing to disclose.
RI PT
References: 1.
2.
SC
3.
Albayram S, Ozer H, Sarici A, Murphy K, Miller N. Unilateral mydriasis without ophthalmoplegia--a sign of neurovascular compression? Case report. Neurosurgery 2006;58(3):E582-583; discussion E582-583. Antunes JL, Lima JA. [Neurovascular compression syndromes of the posterior fossa]. Acta medica portuguesa 1989;2(4-5):224-230. Auders AG, Aksik IA, Kikut RP, Irbe DL. [Diagnosis of vascular compression of the trigeminal and glossopharyngeal nerve roots]. Zhurnal nevropatologii i psikhiatrii imeni SS Korsakova 1990;90(4):8-11. Blake PY, Mark AS, Kattah J, Kolsky M. MR of oculomotor nerve palsy. AJNR American journal of neuroradiology 1995;16(8):1665-1672. Boch AL, Oppenheim C, Biondi A, Marsault C, Philippon J. Glossopharyngeal neuralgia associated with a vascular loop demonstrated by magnetic resonance imaging. Acta neurochirurgica 1998;140(8):813-818. Good EF. Ptosis as the sole manifestation of compression of the oculomotor nerve by an aneurysm of the posterior communicating artery. Journal of clinical neuroophthalmology 1990;10(1):59-61. Hashimoto M, Ohtsuka K, Akiba H, Harada K. Vascular compression of the oculomotor nerve disclosed by thin-slice magnetic resonance imaging. American journal of ophthalmology 1998;125(6):881-882. Inoue T, Hirai H, Shimizu T, Tsuji M, Shima A, Suzuki F, et al. Ocular neuromyotonia treated by microvascular decompression: usefulness of preoperative 3D imaging: case report. Journal of neurosurgery 2012;117(6):11661169. Jannetta PJ. Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. Journal of neurosurgery 1967;26(1):Suppl:159-162. Nakagawa H, Nakajima S, Nakajima Y, Furuta Y, Nishi O, Nishi K. Bilateral oculomotor nerve palsies due to posterior cerebral arterial compression relieved by microvascular decompression--case report. Neurologia medico-chirurgica 1991;31(1):45-48. Silva Jr EB, Ramina R, Meneses MS, Kowacs PA, Silva EB. Bilateral oculomotor nerve palsies due to vascular conflict. Arquivos de neuro-psiquiatria 2010;68(5):819-821. Suzuki K, Muroi A, Kujiraoka Y, Takano S, Matsumura A. Oculomotor palsy treated by microvascular decompression. Surgical neurology 2008;70(2):210-212. Tilikete C, Vial C, Niederlaender M, Bonnier PL, Vighetto A. Idiopathic ocular neuromyotonia: a neurovascular compression syndrome? Journal of neurology, neurosurgery, and psychiatry 2000;69(5):642-644.
M AN U
4. 5.
6.
8.
9.
AC C
10.
EP
TE D
7.
11.
12.
13.
ACCEPTED MANUSCRIPT
Versino M, Colnaghi S, Todeschini A, Candeloro E, Ravaglia S, Moglia A, et al. Ocular neuromyotonia with both tonic and paroxysmal components due to vascular compression. Journal of neurology 2005;252(2):227-229.
RI PT
14.
Figure Legends
SC
Figure 1. Computer tomography (CT) angiogram (A) cerebral angiogram (B) depicting the asymmetry in the origin and course of right posterior cerebral artery.
M AN U
Figure 2. MRI FIESTA sequence showing the signal void of the vessel at the facinity of the right oculomotor nerve.
AC C
EP
TE D
Figure 3. Intraoperative photos showing the superior cerebellar artery (SCA) away from the oculomotr nerve and the posterior cerebral artery (PCA) compressing the oculomotor nerve (Left photo). The microvascular decompression of oculomotor nerve using Teflon is showen on right intraoperative photo.
ACCEPTED MANUSCRIPT
Age Sex
Vascular Compression P2 (PCA) bilateral
Approach
outcome
Note
Female On MRI Basilar A.
Lt. frontotemporal craniotomy Rt. Subtemporal craniotomy -----------
Improved in 2 months -----------
PCOM Aneurysm 3mm -----------
Improved in 1month -----------
PCom Aneurysm 4mm ------------
Male
Male
PCA and SCA
Lt. pterional craniotomy
Silva (2010)
56
Male
Refused surgry
Present case
16
Male
On MRI Rt. PCA and Lt. SCA P2 (PCA)
SC
Nakagawa. 59 (1991) Hashimoto. 74 (1998) Suzuki. (2008) 76
RI PT
Author (Year)
M AN U
Rt. Subtemporal craniotomy
Improved in follow up
-------------
AC C
EP
TE D
Abbreviations : (PCA) posterior cerebral artery, PCOM ( posterior communicating ),A (artery) ,MRI (Magnetic resonant imaging ), SCA ( superior cerebellar artery ), Rt. ( right) and Lt. (left).
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Keywords: Oculomotor Palsy, Microvascular Decompression
Hussein Kheshaifati
AC C
EP
TE D
M AN U
SC
RI PT
Best regards
S1878-8750(15)01790-8
DOI:
10.1016/j.wneu.2015.12.083
Reference:
WNEU 3583
To appear in:
World Neurosurgery
Received Date: 25 August 2015 Revised Date:
23 December 2015
Accepted Date: 24 December 2015
Please cite this article as: kheshaifati H, Al-Otaibi F, Alhejji M, Microvascular Decompression for Oculomotor Nerve Palsy: A Case Report and Literature Review, World Neurosurgery (2016), doi: 10.1016/j.wneu.2015.12.083. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Microvascular Decompression for Oculomotor Nerve Palsy: A Case Report and Literature Review
a
RI PT
Hussein kheshaifati, MBBSa,✭, Faisal Al-Otaibi, MDb,c, Maher Alhejji, MDa
Department of Neurosurgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
b
✭
Medical School, Lebanese American University
Corresponding author
Hussein kheshaifati, MBBS
M AN U
c
TE D
Prince Sultan Military Medical City, Department of Neurosurgery Riyadh, Saudi Arabia
AC C
EP
Email : [email protected]
SC
Division of Neurosurgery, Neuroscience Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
ACCEPTED MANUSCRIPT
RI PT
Abstract: Introduction: Oculomotor nerve palsy can result as a manifestation of diabetic mellitus or aneurysmal compression. Vascular loop compression is a very rare etiology of
SC
oculomotor nerve palsy. Here we present a case report of microvascular decompression
M AN U
for oculomotor nerve palsy.
Case Report: We present a 16-year-old male, otherwise healthy, who presented with right oculomotor nerve palsy for a period of one year. Aneurysmal compression and intracranial lesion have been ruled out by cerebral angiogram and magnetic resonance imaging (MRI). The presence of vessel loop compression on the nerve was suspected
TE D
based on MRI feature. The patient underwent microvascular decompression via a right subtemporal approach. We intraoperatively confirmed vessel loop compression at the exit zone of the nerve from midbrain. Subsequently, the patient’s oculomotor palsy has
EP
improved gradually over a period of six months.
AC C
Conclusions: Vascular compression of the oculomotor nerve is a very rare finding in neurosurgical practice. A diagnosis of vascular compression is made by excluding other pathologies and utilizing high-resolution images that visualize the nerve and the offending vessel loop. Microvascular decompression can be an effective treatment method for this condition. Keywords: Oculomotor Palsy, Microvascular Decompression
ACCEPTED MANUSCRIPT
Introduction:
RI PT
Microvascular decompression is a well-established procedure for the trigeminal and facial nerves.[9] Vascular compression of the oculomotor nerve is extremely rare, and
only a limited number of isolated case reports have been described in the literature.[11]
The advances in neuroimaging have increased the ability to identify the offending vessel
SC
at the surface of the oculomotor nerve and any associated vascular anomalies.[4] Here we
M AN U
report a case of oculomotor palsy treated with microvascular decompression.
Case Report:
We present a 16-year-old male patient, otherwise healthy, who developed a transient right
TE D
ptosis that occurred before one year. At that time he describe an intermittent episodes of right eyelid drop for few days followed by the complete resolution of these symptoms. Recently, he presented with painful right ptosis associated with diplopia for three weeks’
EP
duration. The patient had no history of major trauma or other neurological symptomatology. His physical examination revealed right oculomotor nerve palsy
AC C
features with ptosis, ophthalmoplegia, and moderate mydriasis. The visual acuity and field was normal. The rest of the neurological examination and the systemic examination was unremarkable. The neurologist suspected a right posterior communicating artery (PCA) aneurysm and referred the patient to neurosurgery service.
ACCEPTED MANUSCRIPT
Magnetic resonance imaging (MRI) and cerebral angiography revealed an anatomical variation of the right PCA in the form of asymmetry in the origin as compared to left side and the presence of trifurcation of the P2 segment (Figure 1). No aneurysm or other
RI PT
structural lesions have been identified. MRI FIESTA (fast imaging employing steady
state acquisition sequence) revealed the PCA loop on the surface of the oculomotor nerve (Figure 2). Based on this result, the diagnosis was made as a vascular loop compressing
SC
the oculomotor nerve.
M AN U
Subsequently the patient underwent microvascular decompression of the oculomotor nerve via a subtemporal surgical approach. A vessel loop of the PCA P2 segment was identified intraoperatively to be compressing the oculomotor nerve at the exit zone from the brainstem after the release of arachnoid membranes. Mobilization of the compressing
TE D
artery segment was done to free the nerve, and a piece of Teflon was placed between the artery and the nerve (Figure 3). The superior cerebellar artery was not causing any compression of the nerve. The patient tolerated surgery well, and the oculomotor palsy
EP
improved slowly and gradually over the subsequent period of three months. Complete resolution of the oculomotor palsy was noted after six months of follow-up with a
AC C
sustained resolution at the last follow-up, which occurred one year after the surgery.
Discussion:
Vascular loop compression is known to be the etiology behind trigeminal and glossopharyngeal neuralgias as well as hemifacial spasm.[2, 3, 5] Oculomotor nerve palsy induced by vascular compression is considered very rare. There are limited case reports
ACCEPTED MANUSCRIPT
in the literature.[1, 7, 8, 10-14] Posterior communicating artery aneurysm is a well-known cause of oculomotor palsy.[6] In contrast, vascular anomalies of PCA and the basilar artery could compress the oculomotor nerve, inducing irritation of the nerve that results
RI PT
in dysfunction and in the clinical manifestation of a non-pupillary sparing oculomotor palsy.[10]
SC
The literature to date only contains three case reports of oculomotor palsy treated with
microvascular decompression.[8, 10, 12] Nakagawa and colleagues reported on a 59-year-
M AN U
old man who presented with vascular compression of the oculomotor nerve on the left side that was treated with microvascular compression.[10] Two months later, the patient presented with right oculomotor palsy due to the same etiology and was likewise treated with microvascular decompression. Suzuki et al. reported a case of a 76-year-old man
TE D
who was operated on for a PCA aneurysm.[12] However, the surgeon did not find any compression of the third nerve by the aneurysm. The surgeon followed the nerve posteriorly and identified a compression of the nerve by both posterior communicating
EP
and superior cerebellar arteries. Another case report described an elderly patient with ocular neuromyotonia due to vascular compression of the oculomotor nerve; this patient
AC C
was treated with microvascular decompression.[8]
Our patient is very young in comparison to the patients described in the literature. The vascular decompression was identified by thin cut MRI and the trifurcation of the PCA was identified by a cerebral angiogram. The patient’s improvement after microvascular decompression was gradual and occurred over a period longer than six months, which
ACCEPTED MANUSCRIPT
was a slow recovery as compared to the rapid improvements described in the literature. We found that a subtemporal approach is optimal for the identification of vascular compression and that this approach was the most commonly used in the previously
RI PT
described case reports.[8, 10, 12]
On the other hand, there are limited case reports for oculomotor nerve vascular
SC
compression without surgical treatment. Hashimoto described a case of a 74-year-old woman with oculomotor palsy due to a tortuous basilar artery identified by a thin cut
M AN U
MRI.[7] Silva and colleagues reported on a patient with bilateral oculomotor nerve palsy caused by vascular compression.[11] Other investigators described unilateral ocular neuromyotonia with oculomotor nerve vascular compression.[13, 14]
TE D
The pathophysiology of oculomotor nerve palsy is likely to be similar to trigeminal neuralgia. Ephaptic neural transmission due to demyelination within a segment of the nerve caused by vascular decompression is so far the most widely accepted hypothesis.
AC C
mechanism.
EP
The improvement after microvascular decompression supports the aforementioned
Conclusion:
Oculomotor nerve palsy can very occasionally be induced by vascular compression. Other etiologies need to be excluded in conjunction with high-resolution thin cut MRI to identify the vascular compression. Microvascular decompression can be considered an effective and safe treatment.
ACCEPTED MANUSCRIPT
Disclosure: The authors have nothing to disclose.
RI PT
References: 1.
2.
SC
3.
Albayram S, Ozer H, Sarici A, Murphy K, Miller N. Unilateral mydriasis without ophthalmoplegia--a sign of neurovascular compression? Case report. Neurosurgery 2006;58(3):E582-583; discussion E582-583. Antunes JL, Lima JA. [Neurovascular compression syndromes of the posterior fossa]. Acta medica portuguesa 1989;2(4-5):224-230. Auders AG, Aksik IA, Kikut RP, Irbe DL. [Diagnosis of vascular compression of the trigeminal and glossopharyngeal nerve roots]. Zhurnal nevropatologii i psikhiatrii imeni SS Korsakova 1990;90(4):8-11. Blake PY, Mark AS, Kattah J, Kolsky M. MR of oculomotor nerve palsy. AJNR American journal of neuroradiology 1995;16(8):1665-1672. Boch AL, Oppenheim C, Biondi A, Marsault C, Philippon J. Glossopharyngeal neuralgia associated with a vascular loop demonstrated by magnetic resonance imaging. Acta neurochirurgica 1998;140(8):813-818. Good EF. Ptosis as the sole manifestation of compression of the oculomotor nerve by an aneurysm of the posterior communicating artery. Journal of clinical neuroophthalmology 1990;10(1):59-61. Hashimoto M, Ohtsuka K, Akiba H, Harada K. Vascular compression of the oculomotor nerve disclosed by thin-slice magnetic resonance imaging. American journal of ophthalmology 1998;125(6):881-882. Inoue T, Hirai H, Shimizu T, Tsuji M, Shima A, Suzuki F, et al. Ocular neuromyotonia treated by microvascular decompression: usefulness of preoperative 3D imaging: case report. Journal of neurosurgery 2012;117(6):11661169. Jannetta PJ. Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. Journal of neurosurgery 1967;26(1):Suppl:159-162. Nakagawa H, Nakajima S, Nakajima Y, Furuta Y, Nishi O, Nishi K. Bilateral oculomotor nerve palsies due to posterior cerebral arterial compression relieved by microvascular decompression--case report. Neurologia medico-chirurgica 1991;31(1):45-48. Silva Jr EB, Ramina R, Meneses MS, Kowacs PA, Silva EB. Bilateral oculomotor nerve palsies due to vascular conflict. Arquivos de neuro-psiquiatria 2010;68(5):819-821. Suzuki K, Muroi A, Kujiraoka Y, Takano S, Matsumura A. Oculomotor palsy treated by microvascular decompression. Surgical neurology 2008;70(2):210-212. Tilikete C, Vial C, Niederlaender M, Bonnier PL, Vighetto A. Idiopathic ocular neuromyotonia: a neurovascular compression syndrome? Journal of neurology, neurosurgery, and psychiatry 2000;69(5):642-644.
M AN U
4. 5.
6.
8.
9.
AC C
10.
EP
TE D
7.
11.
12.
13.
ACCEPTED MANUSCRIPT
Versino M, Colnaghi S, Todeschini A, Candeloro E, Ravaglia S, Moglia A, et al. Ocular neuromyotonia with both tonic and paroxysmal components due to vascular compression. Journal of neurology 2005;252(2):227-229.
RI PT
14.
Figure Legends
SC
Figure 1. Computer tomography (CT) angiogram (A) cerebral angiogram (B) depicting the asymmetry in the origin and course of right posterior cerebral artery.
M AN U
Figure 2. MRI FIESTA sequence showing the signal void of the vessel at the facinity of the right oculomotor nerve.
AC C
EP
TE D
Figure 3. Intraoperative photos showing the superior cerebellar artery (SCA) away from the oculomotr nerve and the posterior cerebral artery (PCA) compressing the oculomotor nerve (Left photo). The microvascular decompression of oculomotor nerve using Teflon is showen on right intraoperative photo.
ACCEPTED MANUSCRIPT
Age Sex
Vascular Compression P2 (PCA) bilateral
Approach
outcome
Note
Female On MRI Basilar A.
Lt. frontotemporal craniotomy Rt. Subtemporal craniotomy -----------
Improved in 2 months -----------
PCOM Aneurysm 3mm -----------
Improved in 1month -----------
PCom Aneurysm 4mm ------------
Male
Male
PCA and SCA
Lt. pterional craniotomy
Silva (2010)
56
Male
Refused surgry
Present case
16
Male
On MRI Rt. PCA and Lt. SCA P2 (PCA)
SC
Nakagawa. 59 (1991) Hashimoto. 74 (1998) Suzuki. (2008) 76
RI PT
Author (Year)
M AN U
Rt. Subtemporal craniotomy
Improved in follow up
-------------
AC C
EP
TE D
Abbreviations : (PCA) posterior cerebral artery, PCOM ( posterior communicating ),A (artery) ,MRI (Magnetic resonant imaging ), SCA ( superior cerebellar artery ), Rt. ( right) and Lt. (left).
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Keywords: Oculomotor Palsy, Microvascular Decompression
Hussein Kheshaifati
AC C
EP
TE D
M AN U
SC
RI PT
Best regards