This case report highlights a critical and emergent condition, isolated third nerve cranial palsy due to a brain aneurysm. It emphasizes the importance of differential diagnosis and attentiveness to the physical exam in an emergency setting. The detailed progression from initial symptoms and misinterpretation to final diagnosis offers valuable insight into the dangers of overlooking critical diagnoses. A bilobed intracranial aneurysm arising from the internal carotid artery (ICA) caused symptoms in this patient that could have been attributed to a less malignant etiology, such as a complex migraine. Overlooking the urgency of the situation and missing the diagnosis could have had a grave and irreversible outcome.
References
[1]
Dimopoulos, V.G., Fountas, K.N., Feltes, C.H., Robinson, J.S. and Grigorian, A.A. (2005) Literature Review Regarding the Methodology of Assessing Third Nerve Paresis Associated with Non-Rupture Posterior Communicating Artery Aneurysms. Neurosurgical Review, 28, 256-260. https://doi.org/10.1007/s10143-005-0393-6
[2]
Lai, G. and Scumpia, A.J. (2018) Oculomotor Nerve Palsy Secondary to Cavernous Internal Carotid Aneurysm. Clinical Practice and Cases in Emergency Medicine, 2, 93-94. https://doi.org/10.5811/cpcem.2017.10.35510
[3]
Keane, J.R. (2010) Third Nerve Palsy: Analysis of 1400 Personally-Examined Inpatients. Canadian Journal of Neurological Sciences, 37, 662-670. https://doi.org/10.1017/S0317167100010866
[4]
Fang, C., Leavitt, J.A., Hodge, D.O., Holmes, J.M., Mohney, B.G. and Chen, J.J. (2017) Incidence and Etiologies of Acquired Third Nerve Palsy Using a Population-Based Method. JAMA Ophthalmology, 135, 23-28. https://doi.org/10.1001/jamaophthalmol.2016.4456
[5]
Yanaka, K., Matsumaru, Y., Mashiko R., Hyodo A., Sugimoto K. and Nose, T. (2003) Small Unruptured Cerebral Aneurysms Presenting with Oculomotor Nerve Palsy. Neurosurgery, 52, 553-557. https://doi.org/10.1227/01.NEU.0000047816.02757.39
[6]
White, P.M., Wardlaw, J.M. and Easton, V. (2000) Can Noninvasive Imaging Accurately Depict Intracranial Aneurysms? A Systematic Review. Radiology, 217, 361-370. https://doi.org/10.1148/radiology.217.2.r00nv06361
[7]
Elmalem, V.I., Hudgins, P.A., Bruce, B.B., Newman, N.J. and Biousse, V. (2011) Underdiagnosis of Posterior Communicating Artery Aneurysm Noninvasive Brain Vascular Studies. Journal of Neuro-Ophthalmology, 31, 103-109. https://doi.org/10.1097/WNO.0b013e3181f8d985
[8]
Singh, A., Bahuguna, C., Nagpal, R. and Kumar, B. (2016) Surgical Management of Third Nerve Palsy. Oman Journal of Ophthalmology, 9, 80-86. https://doi.org/10.4103/0974-620X.184509
[9]
Wang, W.X., Xu, B.N., Wang, F.Y., Wu, C. and Sun, Z.H. (2015) Microsurgical Management of Posterior Cerebral Artery Aneurysms: A Report of Thirty Cases in Modern Era. British Journal of Neurosurgery, 29, 406-412. https://doi.org/10.3109/02688697.2015.1004301
[10]
Chaudhry, N.S., Brunozzi, D., Shakur, S.F., Charbel, F.T. and Alaraj, A. (2018) Ruptured Posterior Cerebral Artery Aneurysm Presenting with a Contralateral Cranial Nerve III Palsy: A Case Report. Surgical Neurology International, 9, 52. https://doi.org/10.4103/sni.sni_430_17
[11]
Jacobson, D.M. (2001) Relative Pupil-Sparing Third Nerve Palsy: Etiology and Clinical Variables Predictive of a Mass. Neurology, 56, 797-798. https://doi.org/10.1212/WNL.56.6.797
[12]
Motoyama, Y., Nonaka, J., Hironaka, Y., Park, Y.S. and Nakase, H. (2012) Pupil-Sparing Oculomotor Nerve Palsy Caused by Upward Compression of a Large Posterior Communicating Artery Aneurysm. Case Report. Neurologia Medico-Chirurgica, 52, 202-205. https://doi.org/10.2176/nmc.52.202
