J Korean Ophthalmol Soc.  2018 Apr;59(4):388-392. 10.3341/jkos.2018.59.4.388.

Abducens Nerve Palsy Caused by the Ophthalmic Segment of an Internal Carotid Artery Aneurysm

• Kim I
• Kim JH
• Kim WJ

• KMID: 2409690
• DOI: http://doi.org/10.3341/jkos.2018.59.4.388

Abstract

PURPOSE
To report a case of isolated abducens nerve palsy caused by the ophthalmic segment of an internal carotid artery (ICA) aneurysm which improved after endovascular coil trapping.
CASE SUMMARY
A 59-year-old female visited the ophthalmology department for a sudden onset of horizontal diplopia for 10 days. The best corrected visual acuity was 20/20 in both eyes. The pupils showed normal response to light and near stimulation in both eyes. The extraocular examination showed 35 prism diopters left esotropia at primary gaze and −4 abduction limitation of the left eye. The patient suffered intermittent headaches in the left temporal area and left retrobulbar pain for 1 month. Magnetic resonance imaging with magnetic resonance angiography of the brain was performed. A focal protruding lesion of the left ICA suggested an aneurysm. The patient consulted with the neurosurgery department. The left ophthalmic segment of the ICA aneurysm was confirmed by transfemoral cerebral angiography and treated with coil placement and the patient showed gradual improvement after the procedure. Three months after the procedure there was no diplopia. The patient showed orthotropia at primary gaze without abduction limitation.
CONCLUSIONS
Isolated abducens nerve palsy can be caused by the ophthalmic segment of an ICA aneurysm, which should be considered in the differential diagnosis of ocular motility disorders. The disorder improved with coil replacement treatment. Differential diagnosis as a cause of abducens nerve palsy is important for prompt and appropriate treatment. Neuroimaging should be considered in patients with isolated abducens nerve palsy with a non-ischemic origin.

Keyword

Abducens nerve palsy; Aneurysm; Diplopia; Internal carotid artery

MeSH Terms

Abducens Nerve Diseases*
Abducens Nerve*
Aneurysm*
Brain
Carotid Artery, Internal*
Cerebral Angiography
Diagnosis, Differential
Diplopia
Esotropia
Female
Headache
Humans
Magnetic Resonance Angiography
Magnetic Resonance Imaging
Middle Aged
Neuroimaging
Neurosurgery
Ocular Motility Disorders
Ophthalmology
Pupil
Visual Acuity

Figure

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  Figure 1. Images of the patient in nine diagnostic position of gaze at initial visit. The patient showed esotropia at primary gaze with abduction limitation of the left eye.

• 

  Figure 2. Images of cerebral digital subtraction angiography (DSA) during treatment. (A) Cerebral DSA showed ophthalmic segment aneurysm of left internal carotid artery (neck: 2.80 mm, height: 3.33 mm, width: 3.31 mm, posterior-inferior direction). (B) Cerebral DSA showed two microcatheters were located in the aneurysm. (C, D) Cerebral DSA showed coil embolization was finished with no abnormal findings.

• 

  Figure 3. Images of the patient in nine diagnostic position of gaze at 3 months after the treatment. The patient showed stable ocular alignment without diplopia.

Reference

1). Miller NR, Subramanian PS, Patel VR. Walsh and Hoyt's Clinical Neuro-Ophthalmology: the essentials. 3rd. Philadelphia: Wolters Kluwer;2016. p. 361–9.

2). Jeon C, Sa HS, Oh SY. Causes and natural course of the sixth cranial nerve palsy. J Korean Ophthalmol Soc. 2006; 47:1776–80.

3). Kline LB, Foroozan R. Neuro-Ophthalmology Review Manual. 7th. Thorofare: SLACK;2013. p. 83–122.

4). Hahn CD, Nicolle DA, Lownie SP, Drake CG. Giant cavernous carotid aneurysms: clinical presentation in fifty-seven cases. J Neuroophthalmol. 2000; 20:253–8.

5). Mangat SS, Nayak H, Chandna A. Horner's syndrome and sixth nerve paresis secondary to a petrous internal carotid artery aneurysm. Semin Ophthalmol. 2011; 26:23–4.

6). Oh MJ, Shin DS, Se R, Kim BT. Serpentine cavernous aneurysm presented with visual symptoms improved by endovascular coil trapping. J Cerebrovasc Endovasc Neurosurg. 2016; 18:379–84.

7). Park JY, Koo NK. A giant unruptured aneurysm of distal internal carotid artery presenting with compressice optic neuropathy. J Korean Ophthalmol Soc. 2012; 53:1368–71.

8). Stiebel-Kalish H, Kalish Y, Bar-On RH, et al. Presentation, natural history, and management of carotid cavernous aneurysms. Neurosurgery. 2005; 57:850–7. discussion 850-7.

9). Penchet G, Mourier K. Collaborative retrospective multicentre series of giant intracavernous carotid aneurysms. Neurochirurgie. 2015; 61:366–70.

10). Markwalder TM, Meienberg O. Acute painful cavernous sinus syndrome in unruptured intracavernous aneurysms of the internal carotid artery. Possible pathogenetic mechanisms. J Clin Neuroophthalmol. 1983; 3:31–5.

11). Nguyen DQ, Perera L, Kyle G. Recurrent isolated sixth nerve palsy secondary to an intracavernous carotid artery aneurysm. Eye (Lond). 2006; 20:1416–7.

12). Biousse V, Newman NJ. Neuro-Ophthalmology Illustrated. 2nd. New York: Thieme;2016. p. 321–465.

13). Pane A, Miller NR, Burdon M. The Neuro-Ophthalmology Survival Guide. 2nd. China: Elsevier;2017. p. 169–239.

14). Patel BM, Ahmed A, Niemann D. Endovascular treatment of supraclinoid internal carotid artery aneurysms. Neurosurg Clin N Am. 2014; 25:425–35.

15). van Rooij WJ, Sluzewski M. Unruptured large and giant carotid artery aneurysms presenting with cranial nerve palsy: comparison of clinical recovery after selective aneurysm coiling and therapeutic carotid artery occlusion. AJNR Am J Neuroradiol. 2008; 29:997–1002.