Rate of third nerve palsy recovery following endovascular management of cerebral aneurysms

Ketan R. Bulsara; Daniel Jackson; George M. Galvan

doi:10.1007/s10143-007-0089-1

Neurosurgical Review

October 2007, Volume 30, Issue 4, pp 307–311 | Cite as

Rate of third nerve palsy recovery following endovascular management of cerebral aneurysms

Authors
Authors and affiliations

Ketan R. BulsaraEmail author
Daniel Jackson
George M. Galvan

Original Article

First Online: 26 June 2007

Received: 11 November 2006

Revised: 19 February 2007

Accepted: 04 March 2007

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6 Citations

Abstract

Endovascular management of cerebral aneurysms resulting in third nerve palsies has been proposed as an alternative to microsurgical clip ligation. Third nerve function recovery following endovascular treatment in a large patient population has not been evaluated. A literature search of MEDLINE, PubMed, and Cochrane databases for third nerve palsies and endovascular management of cerebral aneurysms was performed. All reported patients in these studies were systematically compiled. Fifty-two patients with third nerve palsies secondary to cerebral aneurysms underwent endovascular treatment. Endovascular management resulted in some degree of third nerve recovery in 65% of patients. The extent of recovery was reported in 21 patients. Of these, 71% had complete recovery. At least two procedure-related third nerve palsies are reported in the literature. One was permanent. One case of recurrent painful palsy is also reported. Microsurgical clip ligation of cerebral aneurysms has a 93% rate of third nerve palsy recovery and a 43% rate of complete third nerve recovery. Endovascular management of cerebral aneurysms can alleviate third nerve palsies in some patients. In reviewing the world literature, however, microsurgical clip ligation is associated with a higher rate of third nerve recovery. Endovascular management, in the subset of patients in whom extent of recovery was documented, demonstrated a higher rate of complete recovery.

Keywords

Microsurgery Endovascular Third nerve palsy Oculomotor nerve

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Notes

Comments

Alexander Brawanski, Regensburg, Germany

In their paper Bulsara et al. perform a meta-analysis of the effect of coiling on third nerve palsy. All in all they found 52 cases, 65% of which showed a third nerve recovery. The extent of recovery, however, was reported in 21 patients only. Of these 71% had a complete recovery.

As the authors state themselves the data are scant and not totally conclusive, in contrast to data of patients with clipped aneurysms. In principle it is not unexpected that coiling has a beneficial effect on third nerve palsy comparable to clipping. The major effect for recovery seems to be attributable to the missing transmission of blood pulsations as well as the decrease of the volume effect of the aneurysm. This can be achieved through most modalities. However, I would be careful about stating that coiling is better than operation based on the existent data. Further proof for this—possible—assumption is necessary, as the authors say themselves.

Comments

Liang-Fu Zhou, Shanghai, China

In this manuscript, Dr. Bulsara and colleagues review the current knowledge and literature on recovery of third nerve function following endovascular intervention for intracranial aneurysms. They collected 52 patients presenting with oculomotor nerve palsy (ONP) due to compression of the third nerve by cerebral aneurysms. The aneurysms included 34 basilar tip aneurysms, 10 posterior communicating artery (PCoA) aneurysms, 3 superior cerebellar artery aneurysms, 1 internal carotid cavernous sinus artery aneurysm, and 4 aneurysms with location not reported. After endovascular intervention, 34 patients (65%) had some degree of recovery from ONP. In 21 patients (42%) for whom the extent of recovery was reported, 15 patients (71%) gained full recovery, 2 patients (16%) partial recovery, and 4 (19%) remained unchanged. From the current data, unfortunately, the authors could not draw a conclusion regarding the timing of endovascular intervention and the recovery from ONP. The authors also collected data about the effect of surgical clipping on aneurysmal ONP in the literature and found that recovery was achieved in 93% of patients, including complete recovery in 41% and unchanged in 7%. Moreover, 64% of patients treated surgically within 14 days of onset of ONP had complete recovery, only 14% of patients treated over 30 days had complete recovery. Therefore, the authors conclude that a greater percentage of the recovery from ONP is achieved in microsurgical patients. A higher percentage of complete recovery, however, is found in coiling patients.

This is the first summary of a large patient population undergoing endovascular intervention for intracranial aneurysms and its effect on ONP, although there are some limitations in the study as mentioned by the authors. Moreover, I believe caution is warranted in drawing any meaningful conclusion when comparing reports from the literature on clipping versus coiling, because there is enough heterogeneity regarding patient and aneurysm conditions, and marked difference in the assessment of ONP and its recovery among different series.

Recently, there were three important articles published, which were not referred to by Dr. Bulsara et al. Therefore, a brief introduction is made for our readership.

Stiebel-Kalish et al. [1] provided a neuro-ophthalmological perspective of 11 patients with PCoA aneurismal ONP treated by coiling. At the 1-year follow-up study, there were residual deficits in all patients that were mild in 4 and moderate or severe in 7. After comparing their results with those of Yanaka et al., the authors concluded that ONP improves comparable with the recovery observed after surgical clipping. This is a careful multidisciplinary study in a single institution, addressing an important issue, the recovery from ONP, with resolution of diplopia in primary gaze. However, the study suffered from statistical weakness, small size, and a not strictly matched control group.

Chen et al. [2] retrospectively evaluated the outcome of ONP in 13 patients who underwent endovascular intervention (6) or surgical clipping (7) of a PCoA in their institution. Six of seven surgical patients with ONP recovered completely compared with two of six patients in the endovascular group. Of the patients with more than 1-year follow-up, all surgical patients recovered completely compared with two of four endovascular patients. That means surgical clipping appears to be superior for recovery of ONP (especially complete deficits), in competent surgical and endovascular hands. Interestingly, the authors also demonstrated that the preoperative degree of ONP significantly affected recovery, and the length of time from onset of ONP to treatment, the patient’s age, and the aneurysm size were not associated with likelihood of resolution. Moreover, the authors point out that there is no difference in the recovery of ONP in patients whose aneurysmal sac had been puncture-decompressed compared with those whose had not.

Obviously, this study has a limitation inherent for a retrospective study and small size. More reports on their topic and verification of their findings need to be reported by other centers.

Dimopoulos et al. [3] review the relevant literature regarding the methodology of assessing ONP associated with non-ruptured PCoA aneurysm and propose a classification system for the severity of ONP, correlating it well to the postoperative recovery in their five patients. This is a simple grading system and can be a helpful tool for the evaluation, monitoring, and comparison of the recovery of ONP in different carters.

Finally, as Dr. Bulsara et al. proposed, for answering the debate on whether clipping or coiling is better in the treatment of aneurysmal ONP and offering more correct information to our patients and their family prior to treatment, a prospective randomized control trial in multiple centers will be warranted.

References

1. Stiebel-Kalish H, Maimon S, Amsalem J, Erlich R, Kalish Y, Rappaport HZ (2003) Evolution of oculomotor nerve paresis after endovascular coiling of posterior communicating artery aneurysms: a neuro-ophthalmological perspective. Neurosurgery 53:1268–1273

2. Chen PR, Amin-Hanjani S, Albuquerque FC, McDougall C, Zabramski JM, Spetzler RF (2006) Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling. Neurosurgery 58:1040–1046

3. Dimopoulos VG, Fountas KN, Feltes CH, Robinson JS, Grigorian AA (2005) Literature review regarding the methodology of assessing third nerve paresis associated with non-ruptured posterior communicating artery aneurysms. Neurosurg Rev 28:256–260

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Authors and Affiliations

Ketan R. Bulsara
- 1
Email author
Daniel Jackson
- 2
George M. Galvan
- 3

1.Department of NeurosurgeryYale University School of MedicineNew Haven, ConnecticutUSA
2.University of Missouri-ColumbiaColumbiaUSA
3.University of Texas-San AntonioSan AntonioUSA

Rate of third nerve palsy recovery following endovascular management of cerebral aneurysms

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