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

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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.

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References

  1. Bhatti MT, Peters KR, Firment C, Mericle RA (2004) Delayed exacerbation of third nerve palsy due to aneurysmal regrowth after endovascular coil embolization. J Neuroophthalmol 24:3–10

    PubMed  Google Scholar 

  2. Birchall D, Khangure MS, McAuliffe W (1999) Resolution of third nerve paresis after endovascular management of aneurysms of the posterior communicating artery. AJNR Am J Neuroradiol 20:411–413

    PubMed  CAS  Google Scholar 

  3. Botterell EH, Lloyd LA, Hoffman HJ (1962) Oculomotor palsy due to supraclinoid internal carotid artery berry aneurysm. A long-term study of the results of surgical treatments on the recovery of third-nerve function. Am J Ophthalmol 54:609–616

    Google Scholar 

  4. Eskridge JM, Song JK (1998) Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coils: results of the Food and Drug Administration multicenter clinical trial. J NSU 89:81–86

    Google Scholar 

  5. Ezura M, Tkahasi A, Ogasawara K, Yoshimoto T (1997) Intra-aneurysmal GDC embolization followed by inrathecal tPA administration for poor-grade basilar tip aneurysm. Surg Neurol 47:144–147

    Google Scholar 

  6. Feely M, Kapoor S (1987) Third nerve palsy due to posterior communicating artery aneurysm: the importance of early surgery. J Neurol Neurosurg Psychiatry 50:1051–1052

    PubMed  CAS  Google Scholar 

  7. Fujiwara S, Fujii K, Nishio S, Matsushima T, Fukui M (1989) Oculomotor nerve palsy in patients with cerebral aneurysms. Neurosurg Rev 12:123–132

    Article  PubMed  CAS  Google Scholar 

  8. Giombini S, Ferraresi S, Pluchino F (1991) Reversal of oculomotor disorders after intracranial aneurysm surgery. Acta Neurochir (Wien) 112:19–24

    Article  CAS  Google Scholar 

  9. Goddard AJ, Annesley-Williams D, Gholkar A (2002) Endovascular management of unruptured intracranial aneurysms: does outcome justify treatment? J Neurol Neurosurg Psychiatry 72:485–490

    Google Scholar 

  10. Grayson MC, Soni SR, Spooner VA (1974) Analysis of the recovery of third nerve function after direct surgical intervention for posterior communicating aneurysms. Br J Ophthalmol 58:118–125

    PubMed  CAS  Google Scholar 

  11. Gruber A, Killer M, Bavinzski G, Richling B (1999) Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year, single center experience. Neurosurgery 45:793–803

    Google Scholar 

  12. Halbach VV, Higashida RT, Dowd CF, Barnwell SL, Fraser KW, Smith TP, Teitelbaum GP, Hieshima GB (1994) The efficacy of endosaccular aneurysm occlusion in alleviating neurological deficits produced by mass effect. J Neurosurg 80:659–666

    PubMed  CAS  Google Scholar 

  13. Hamer J (1982) Prognosis of oculomotor palsy in patients with aneurysms of the posterior communicating artery. Acta Neurochir (Wien) 66:173–185

    Article  CAS  Google Scholar 

  14. Horowitz MB, Levy E, Kassam A, Purdy PD (2002) Endovascular therapy for intracranial aneurysms: a historical and present status review. Surg Neurol 57:147–158; discussion 158–149

    Article  PubMed  Google Scholar 

  15. Horowitz MB, Purdy PD, Burns D, Bellotto D (1997) Scanning electron microscopic findings in a basilar tip aneurysm embolized with Guglielmi detachable coils. AJNR Am J Neuroradiol 18:688–690

    PubMed  CAS  Google Scholar 

  16. Hyland HH, Barnett HJ (1954) The pathogenesis of cranial nerve palsies associated with intracranial aneurysms. Proc R Soc Med 47:141–146

    PubMed  CAS  Google Scholar 

  17. Inamasu J, Nakamura Y, Saito R, Kuroshima Y, Ohba S, Ichikizaki K (2002) Early resolution of third nerve palsy following endovascular treatment of a posterior communicating artery aneurysm. J Neuroophthalmol 22:12–14

    PubMed  Google Scholar 

  18. Kwon BJ, Han MH, Oh CW, Kim KH, Chang KH (2003) Procedure-related haemorrhage in embolisation of intracranial aneurysms with Guglielmi detachable coils. Neuroradiology 45:562–569

    Article  PubMed  CAS  Google Scholar 

  19. Kyriakides T, Aziz TZ, Torrens MJ (1989) Postoperative recovery of third nerve palsy due to posterior communicating aneurysms. Br J Neurosurg 3:109–111

    PubMed  CAS  Google Scholar 

  20. Lanzino G, Andreoli A, Tognetti F, Limoni P, Calbucci F, Bortolami R, Lucchi ML, Callegari E, Testa C (1993) Orbital pain and unruptured carotid-posterior communicating artery aneurysms: the role of sensory fibers of the third cranial nerve. Acta Neurochir (Wien) 120:7–11

    Article  CAS  Google Scholar 

  21. Leivo S, Hernesniemi J, Luukkonen M, Vapalahti M (1996) Early surgery improves the cure of aneurysm-induced oculomotor palsy. Surg Neurol 45:430–434

    Article  PubMed  CAS  Google Scholar 

  22. Louw DF, Asfora WT, Sutherland GR (2001) A brief history of aneurysm clips. Neurosurg Focus 11:E4

    PubMed  CAS  Google Scholar 

  23. Malisch TW, Guglielmi G, Vinuela F, Duckwiler G, Gobin YP, Martin NA, Frazee JG, Chmiel JS (1998) Unruptured aneurysms presenting with mass effect symptoms: response to endosaccular treatment with Guglielmi detachable coils. Part I. Symptoms of cranial nerve dysfunction. J Neurosurg 89:956–961

    PubMed  CAS  Google Scholar 

  24. McFadzean RM, Teasdale EM (1998) Computerized tomography angiography in isolated third nerve palsies. J Neurosurg 88:679–684

    Article  PubMed  CAS  Google Scholar 

  25. Molyneux A, Kerr R (1999) International Subarachnoid Aneurysm Trial. J Neurosurg 91:352–353

    PubMed  CAS  Google Scholar 

  26. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R (2002) International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274

    Article  PubMed  Google Scholar 

  27. Padolecchia R, Guglielmi G, Puglioli M, Castagna M, Nardini V, Collavoli PL, Guidetti G, Dazzi M, Zucchi V, Narducci P (2001) Role of electrothrombosis in aneurysm treatment with Guglielmi detachable coils: an in vitro scanning electron microscopic study. AJNR Am J Neuroradiol 22:1757–1760

    PubMed  CAS  Google Scholar 

  28. Preechawat P, Sukawatcharin P, Poonyathalang A, Lekskul A (2004) Aneurysmal third nerve palsy. J Med Assoc Thai 87:1332–1335

    PubMed  Google Scholar 

  29. Renowden SA, Harris KM, Hourihan MD (1993) Isolated atraumatic third nerve palsy: clinical features and imaging techniques. Br J Radiol 66:1111–1117

    Article  PubMed  CAS  Google Scholar 

  30. Soni SR (1974) Aneurysms of the posterior communicating artery and oculomotor paresis. J Neurol Neurosurg Psychiatry 37:475–484

    Article  PubMed  CAS  Google Scholar 

  31. Sorteberg A, Sorteberg W, Rappe A, Strother CM (2002) Effect of Guglielmi detachable coils on intraaneurysmal flow: experimental study in canines. AJNR Am J Neuroradiol 23:288–294

    PubMed  Google Scholar 

  32. Stiver SI, Porter PJ, Willinsky RA, Wallace MC (1998) Acute human histopathology of an intracranial aneurysm treated using Guglielmi detachable coils: case report and review of the literature. Neurosurgery 43:1203–1208

    Article  PubMed  CAS  Google Scholar 

  33. Tamatani S, Ito Y, Abe H, Koike T, Takeuchi S, Tanaka R (2002) Evaluation of the stability of aneurysms after embolization using detachable coils: correlation between stability of aneurysms and embolized volume of aneurysms. AJNR Am J Neuroradiol 23:762–767

    PubMed  Google Scholar 

  34. Thorell WE, Chow MM, Woo HH, Masaryk TJ, Rasmussen PA (2005) Y-configured dual intracranial stent-assisted coil embolization for the treatment of wide-necked basilar tip aneurysms. Neurosurgery 56:1035–1040; discussion 1035–1040

    PubMed  Google Scholar 

  35. Uda K, Murayama Y, Gobin YP, Duckwiler GR, Vinuela F (2001) Endovascular treatment of basilar artery aneurysm with Guglielmi detachable coils: clinical experience with 41 aneurysms in 39 patients. J NSU 95:624–632

    CAS  Google Scholar 

  36. Ushikoshi S, Kikuchi Y, Houkin K, Miyasaka K, Abe H (1999) Aggravation of brainstem symptoms caused by a large superior cerebellar artery aneurysm after embolization by Guglielmi detachable coils—case report. Neurol Med Chir (Tokyo) 39:524–529

    Article  CAS  Google Scholar 

  37. Yanaka K, Matsumaru Y, Mashiko R, Hyodo A, Sugimoto K, Nose T (2003) Small unruptured cerebral aneurysms presenting with oculomotory palsy. Neurosurgery 52:553–557

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, TMP 4, New Haven, Connecticut, CT, 06520, USA

    Ketan R. Bulsara

  2. University of Missouri-Columbia, Columbia, MO, USA

    Daniel Jackson

  3. University of Texas-San Antonio, San Antonio, TX, USA

    George M. Galvan

Authors
  1. Ketan R. Bulsara
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  2. Daniel Jackson
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  3. George M. Galvan
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Correspondence to Ketan R. Bulsara.

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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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Bulsara, K.R., Jackson, D. & Galvan, G.M. Rate of third nerve palsy recovery following endovascular management of cerebral aneurysms. Neurosurg Rev 30, 307–311 (2007). https://doi.org/10.1007/s10143-007-0089-1

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