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Clin Exp Emerg Med > Volume 1(1); 2014 > Article
Kim and Choi: Third cranial nerve palsy and posterior communicating artery aneurysm
A 64-year-old woman with a history of diabetes mellitus and smoking was admitted to the emergency department because of headache, vomiting, binocular diplopia and right-sided ptosis. Five days earlier, she had a sudden headache of a stabbing nature in the right frontal area, which recurred every 5 hours. The visual analogue scale (VAS) score for pain was 8. Three days later, she noticed binocular diplopia and right-sided ptosis (Fig. 1A, B). Neurologic examination revealed right-sided third cranial nerve palsy with ipsilateral pupil dilation and no other definite focal neurologic deficits. Computed tomography (CT) scan and CT 3-D angiography revealed a 1-cm saccular aneurysm with lobulated contour in the right posterior communicating artery (Fig. 2A, B). On neurosurgical consultation, coil embolization of the aneurysm was performed successfully. The initial symptoms improved after 2 weeks and completely resolved after a 3-month follow-up in the outpatient department.
Unless proven otherwise, acute third cranial nerve palsy with ipsilateral pupillary dilatation is caused by a posterior communicating artery aneurysm [1]. Concomitant headache is a frequent symptom [1,2]. Expansion of such aneurysm may cause compression of the outer fibers of third cranial nerve palsy [1,2]. The pupillomotor fibers are located in the outer portion of this nerve; therefore, the pupil becomes dilated on the affected side. The posterior communicating artery can rupture spontaneously [3,4]. Treatment involves emergent blood pressure reduction if hypertensive, and neuroimaging and neurosurgical intervention [5].

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Newman SA. Aneurysms; In: Miller NR, Newman NJ, editors. Walsh and Hoyt’s clinical neuro-ophthalmology. 5th ed. Baltimore, MD: Williams & Wilkins; 1998. p.3075-83.

2. Soni SR. Aneurysms of the posterior communicating artery and oculomotor paresis. J Neurol Neurosurg Psychiatry 1974; 37:475-84.
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3. De la Monte SM, Moore GW, Monk MA, Hutchins GM. Risk factors for the development and rupture of intracranial berry aneurysms. Am J Med 1985; 78(6 Pt 1):957-64.
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4. Okawara SH. Warning signs prior to rupture of an intracranial aneurysm. J Neurosurg 1973; 38:575-80.
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5. Nelson PK, Levy D, Masters LT, Bose A. Neuroendovascular management of intracranial aneurysms. Neuroimaging Clin N Am 1997; 7:739-62.
pmid

Fig. 1.
Right-sided third cranial nerve palsy with ipsilateral pupil dilation was shown in images.
ceem-14-002f1.tif
Fig. 2.
A 1-cm saccular aneurysm with lobulated contour in the right posterior communicating artery was shown in computed tomography (CT) scan and three-dimensional CT angiography.
ceem-14-002f2.tif
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