Pre-rupture syndrome

Abstract

Oculomotor nerve palsy can be a strong indicator of an internal carotid artery aneurysm, specifically of the posterior communicating artery, due to the anatomical positioning within the basal cisterns of the subarachnoid space, which allows for nerve compression. This condition can predict an acute subarachnoid haemorrhage, associated with a high mortality rate, often presenting with sudden, severe headaches, with or without deficits. The pathophysiology theories include direct mechanical compression by the aneurysmal sac, arterial pulsations, and nerve tissue oedema from venous obstruction. In cases of unruptured aneurysms, nerve irritation is less common. This palsy occurs in about one-third of cases. Aneurysmal orientation can vary (lateral, superior, inferior, medial, posterior), and due to the nerve’s anatomical position, aneurysms in the postero-lateral-inferior position are more likely to cause nerve damage. Treatment opinions vary from observation to intervention, with options including traditional neurosurgery and endovascular embolization. The latter is increasingly preferred due to its efficacy and lower risk profile. A clinical case involves a 56-year-old female presenting with ptosis, diplopia, and ipsilateral mydriasis. Imaging confirmed a posterior communicating artery aneurysm with a maximum diameter of 5.3 mm and a 3 mm bleb. Endovascular coiling was performed successfully, excluding the aneurysm from circulation without complications. Post-treatment, the patient was discharged in good condition with recommendations for periodic monitoring. In conclusion, while no single best treatment exists for posterior communicating artery aneurysms with oculomotor nerve palsy, early intervention (surgical or endovascular) and patient monitoring are crucial for preventing complications and ensuring quality of life.