Elsevier

Surgical Neurology

Volume 68, Issue 5, November 2007, Pages 500-504
Surgical Neurology

Aneurysm
Resolution of cranial nerve paresis after endovascular management of cerebral aneurysms

https://doi.org/10.1016/j.surneu.2006.12.061Get rights and content

Abstract

Background

This work aimed to study the outcome of endovascular (coiling and balloon occlusion) treatment in patients with aneurysmal mass effect (ophthalmoplegia due to third, fourth, or sixth CN paresis) and to compare it with the outcome of clipping (from the international literature).

We looked at the outcome of endovascular treatment of CNP (third, fourth, and sixth) due to aneurysmal mass effect (PcomA aneurysms and intracavernous carotid aneurysms).

Methods

Between January 1999 and December 2004, 820 patients presented with aneurysmal SAH and/or mass effect. Eleven of these patients (1%) presented with third, and/or fourth, and/or sixth nerve dysfunctions and underwent endovascular treatment. The degree of the ophthalmoplegia was recorded at presentation, 2 months, 6 months, and yearly intervals thereafter. We correlated recovery of CNP to SAH, duration of the symptoms, degree of CNP, type of CNP, microvascular risks (age, diabetes mellitus, hypertension, and smoking), aneurysm size, and degree of coiling or balloon occlusion.

Results

The study showed a favorable outcome of endovascular treatment in the majority of patients. Resolution of CN dysfunctions occurred in 7 (64%) of 11 patients. The late follow-up showed that all the 7 patients are resuming normal life activities. This compares favorably to the results after clipping in [Leivo, Hemesniemi, Luukkonen, & Vapalahti, 1996] (41%). Presentation with SAH and isolated third CNP correlated with a better resolution of CNP (P < .05).

Conclusion

Although mass effect remains after endovascular packing, CNP improves comparably to the recovery observed after surgical clipping. It seems likely that the decrease in aneurysmal pulsatility is responsible for the improvement of the CNP. The relatively atraumatic approach associated with endovascular management explains the favorable results. All previous reports assessed the outcome of only the third CNP after endovascular treatment in a very limited number of cases. To the best of our knowledge, this is the first study to assess the outcome of various CNP after endovascular treatment.

Introduction

Endovascular treatment is becoming an acceptable alternative to microsurgical clipping for selected intracerebral aneurysms [11]. The effect of endovascular treatment on the recovery of neural function in patients with CNP caused by aneurysmal pressure effect is poorly documented. It has been argued that coiling is less effective in resolving aneurysmal mass effect than clipping as the aneurysm is packed and does not collapse.

We report the outcome of endovascular treatment in 11 patients with third and/or fourth, and/or sixth CN dysfunctions caused by PcomA aneurysms and/or intracavernous aneurysms.

Section snippets

Clinical data and methods

Between January 1999 and December 2004, 820 patients presented with aneurysmal SAH and/or mass effect to Beaumont Hospital. Eleven of these patients presented with third, and/or fourth, and/or sixth nerve dysfunctions and underwent endovascular treatment (1%).

The inclusion criteria were (1) cerebral aneurysm; (2) the presence of third, fourth, or sixth CN dysfunctions, which is explained by the location of the aneurysm; (3) the aneurysm was treated by endovascular Guglielmi detachable coils or

Results

The study population consists of 1 man and 10 women, whose ages ranged from 42 to 75 years (average age, 59 years) (Table 1).

The background medical history was reported (diabetes mellitus, hypertension, and smoking). None of the patients were diabetic, 5 (45%) were hypertensive, and 7 (64%) were smokers. Four (36%) patients were older than 60 years.

We recorded the duration of the ophthalmoplegia before treatment, which ranged from 1 day to 20 weeks (average, 10 weeks). The patients with SAH

Discussion

Endovascular techniques (thrombus occlusion of aneurysm using detachable balloons or coils) have led to improved CNs mass effect symptoms according to few reports [3], [4], [5], [8], [9], [13]. The resolution of oculomotor nerve paresis after endovascular treatment of PcomA was described by Mavilio et al [10], Birchall et al [1], and Stiebel-Kalish et al [12], who reported 6, 3, and 11 patients, respectively. The resolution was described as complete in the first 2 studies and incomplete in the

Conclusion

Endovascular treatment is a viable alternative to clipping for treatment of CNP owing to the aneurysmal mass effect. The results are similar to or may even be better than surgical treatment. It seems that a pattern of aneurysm and patient factors predicting poor recovery can be recognized. More than 1-month duration of CNP, intracavernous carotid aneurysms, absence of SAH, and complete CNP all correlated with poor outcome. The number of cases in this study is small and further studies including

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