Delayed Third Cranial Nerve Palsy After Aneurysm Wrapping

Abstract

Third cranial nerve palsy after aneurysm wrapping may be caused by damage to the nerve during surgical dissection, perianeurysmal inflammation related to the cotton used to wrap the aneurysm, or, if fibrin glue is also used, adherence of the wrapping material to the nerve. In almost all cases, the palsy occurs immediately after surgery. We recently examined a 64-year-old woman who developed a third cranial nerve palsy on the side where, nearly 1 year earlier, she had undergone clipping of a 14-mm aneurysm located at the junction of the internal carotid and posterior communicating arteries. At the time of surgery, a small residual area at the aneurysm base had to be wrapped with cotton and secured with fibrin glue. Intraoperative angiography had confirmed almost complete obliteration of the aneurysm. Postoperatively, the patient had no neurologic or visual deficits. During the year after surgery, she experienced two brief episodes in which, when looking in a mirror, she noticed that her left pupil was dilated. She never had double vision or drooping of her left upper lid at that time. Eleven months after surgery, the patient sustained moderate trauma to her left orbit after she slipped while pushing a metal dolly and struck her head against the handle. She did not lose consciousness or sustain any facial lacerations, but she did develop significant swelling and bruising of the left orbit and face. As the facial swelling resolved during the next month, she noticed binocular double vision and was found to have a partial left third cranial nerve palsy that became complete over the next 5 months. MRI and catheter angiography showed no changes from previous intraoperative imaging, but a lumbar puncture showed an increased protein concentration of 98 mg/dL. The patient was treated with 1 g of intravenous methylprednisolone per day for 3 days, followed by 60 mg of prednisone per day. Two weeks after treatment was started, the patient's third cranial nerve palsy began to improve and continued to improve until the patient stopped treatment because of side effects. Two other cases of delayed third cranial nerve palsy after aneurysm wrapping have been reported (1,2). Onoue et al (1) described a patient who developed a third cranial nerve palsy 6 months after muslin wrapping of an aneurysm located at the junction of the ipsilateral internal carotid and anterior choroidal arteries. Craniotomy disclosed a mass consisting of soft granulomatous tissue mixed with calcified material. Microscopic examination revealed filamentous foreign material and reactive giant cells consistent with a foreign body granuloma. The third cranial nerve palsy resolved several weeks after surgery. Chambi et al (2) described a 71-year-old woman who developed a progressive third cranial nerve palsy 19 months after clipping and wrapping of an aneurysm at the junction of the ipsilateral internal carotid and posterior communicating arteries (2). No treatment was offered. Despite partial improvement in ptosis over the next year, palsy of the superior, medial, and inferior rectus muscles was still present 4 years later. We believe that in our patient the combination of wrapping material and fibrin glue resulted in slight adhesion of the aneurysm to the superior aspect of the third cranial nerve that was then exacerbated by the head trauma. Whatever the mechanism, our patient illustrates the fact that such delayed postoperative complications can occur many months after otherwise uncomplicated aneurysm treatment, particularly when clipping and wrapping are used. Corticosteroid treatment may be effective. Zina Evy Almer, MD Neil R. Miller, MD The Wilmer Eye Institute Johns Hopkins University Baltimore, Maryland [email protected]