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Isolated oculomotor nerve palsy in a child caused by an internal carotid aneurysm Vedang Shah, MBBS, Mahesh Kumar, DO, DNB, Kowsalya Akkayasamy, DO, DNB, and Kunal Rana, DO, DNB, FICO Common causes for acquired isolated oculomotor nerve palsy in children are trauma, inflammation, and neoplasia. We report a case of isolated oculomotor nerve palsy in a 13-year-old boy secondary to intracranial carotid aneurysm. Case Report A 13-year-old south Indian boy presented at the Aravind Eye Hospital, Madurai, with chief symp- toms of headache associated with vomiting of 2 week’s duration, right eye pain of 1 week’s duration, and ptosis of the right upper eyelid and binocular double vision for the previous 2 days. There was no history of fever, ocular trauma, or head injury. General physical examination was unremarkable. On ophthalmological examination, visual acuity was 6/6 in both eyes. Ptosis in the right eye was complete; the pupil was dilated and fixed at 5 mm. Extraocular movements in the right eye were limited in all directions except abduction (Figure 1A). Diplopia and Hess charts were suggestive of oculomotor nerve palsy in the right eye. Left eye findings were normal. Dilated fundus examination was normal in both eyes. Color vision and central field assessment were normal in both eyes. Neurological examination was otherwise normal. Magnetic resonance imaging (MRI) and magnetic reso- nance angiography (MRA) revealed a lesion of mixed signal intensity that involved distal narrowing of the petrous, cavernous, and supraclinoid parts of the internal carotid artery. Digital subtraction angiography revealed a wide-neck saccular, lobulated right cavernous internal carotid artery aneurysm measuring 12.7 7.4 mm, with narrowing of the proximal cavernous internal carotid artery (Figure 2A). Good cross circulation was noted in the anterior communicating artery on right internal ca- rotid artery compression. Based on the clinical history and imaging, the boy was diagnosed with pupil- involving, oculomotor nerve palsy due to internal carotid artery aneurysm. The patient was referred to a neurosurgeon for further management. He underwent balloon-assisted parent artery occlusion of the right cavernous aneurysm using coils and glue. At 1 month’s follow-up, recovery of the right oculomotor nerve palsy was complete, and ptosis and ophthalmoplegia had resolved completely, with minimally sluggish pupillary reaction. No signs of aberrant regeneration were observed (Figures 2B and 1B). Discussion Isolated, acquired oculomotor nerve palsy secondary to intracranial aneurysms are extremely rare in chil- dren. 1 Fox 2 reported a similar case in a 6-year-old with oculomotor nerve palsy due to a giant cavernous carotid aneurysm. Posterior communicating aneurysms have been reported in children 7-11 years of age by Wolin and Saunders, 3 Liu and colleagues, 1 and Bran- ley and colleagues. 4 Tamhankar and colleagues 5 re- ported an 8-month-old girl with internal carotid artery aneurysm that was left untreated due to its fusiform nature. The present case was a saccular aneurysm, which is the least common form of cere- bral aneurysm. The cavernous location of the aneu- rysm was also very uncommon and accounts for only 2% of all intracranial aneurysms. These aneu- rysms most commonly involve the abducens nerve, as the nerve traverses just lateral to the internal ca- rotid artery in the cavernous sinus. Management of internal carotid artery aneurysms require a multidisciplinary approach involving ophthal- mologists, radiologists, and neurosurgeons. Treatment depends on the symptoms, size, and location of the aneurysm. Linskey and colleagues 6 reported improve- ment in 25%-40% of cases with conservative treatment. The decision to intervene typically centers around the persistence of pain, subarachnoid hemorrhage, progres- sive or unresolving ophthalmoplegia, and visual loss. Our patient recovered completely following successful Author affiliations: Aravind Eye Hospital, Madurai, Tamil Nadu, India Submitted April 8, 2013. Revision accepted August 30, 2013. Published online November 7, 2013. Correspondence: Vedang Shah, MBBS, Aravind Eye Hospital.1, Anna nagar, Madurai- 625020, Tamil Nadu, India (email: [email protected]). J AAPOS 2013;17:648-649. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.08.008 Journal of AAPOS 648 Shah et al Volume 17 Number 6 / December 2013
