Background

The oculomotor nerve has two major fibers: the outer autonomic fiber innervates the ciliary muscles and sphincter pupillae involved in pupil constriction, and the inner somatic fiber innervates the levator palpebrae superioris in the eyelid and four extraocular muscles involved in oculomotor dysfunction. We present a rare case of oculomotor nerve palsy with internal carotid artery (ICA) dissection and discuss the vascular anatomical feature of interest to be considered during treatment.

Case report

A 56-year-old man presented with language impairment, right visual field loss, and right-sided facial sensory loss, weakness, and hypesthesia 30 hours after the last seen normal. CT perfusion imaging revealed a large left middle cerebral artery distribution and possible salvageable ischemic penumbra. Angiography showed occlusion of the communicating segment of the left ICA. We performed mechanical thrombectomy for left ICA occlusion that led to partial recanalization after several attempts. A control digital subtraction angiography showed dissection features in the communicating part of the left ICA. The recanalized ICA got blocked again within ten minutes. Angioplasty was performed and the flow improved. Five hours after thrombectomy, the patient developed complete left oculomotor palsy with ptosis, a fixed mydriatic pupil, and lateral and downwards eyeball deviation suggesting oculomotor nerve palsy. MRI on the 23rd day after symptom onset revealed enhancement of the left oculomotor nerve.

Conclusions

The clinical and imaging course described in this case shows an injury to the oculomotor nerve with compressive plus ischemic injury in a patient with ICA dissection who received endovascular treatment.

中文翻译：

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颈内动脉夹层患者血管内治疗后动眼神经麻痹少见

背景

动眼神经有两条主要纤维：外部自主神经支配参与瞳孔收缩的睫状肌和括约肌瞳孔，内部体神经支配眼睑上睑提肌和参与动眼功能障碍的四眼外肌。我们介绍了颈内动脉（ICA）解剖的动眼神经麻痹的罕见情况，并讨论了在治疗过程中需要考虑的感兴趣的血管解剖特征。

案例报告

一名56岁的男子在最后一次看正常后30小时出现语言障碍，右视野丧失和右侧面部感觉丧失，虚弱和感觉异常。CT灌注成像显示左大脑中动脉分布较大，可能可挽救缺血性半影​​。血管造影显示左ICA的通信段闭塞。我们对左ICA阻塞进行了机械血栓切除术，经过多次尝试后导致部分再通。对照数字减影血管造影显示左ICA的连通部分有解剖特征。再通的ICA在十分钟内再次被阻塞。进行血管成形术并改善血流。血栓切除术后五小时，患者发展为完全左眼动瘫并伴有上睑下垂，瞳孔固定，眼球外侧和向下偏离，提示动眼神经麻痹。症状发作后第23天的MRI显示左动眼神经增强。

结论

在这种情况下描述的临床和影像学过程显示，接受血管内治疗的ICA夹层患者的动眼神经受压加缺血性损伤。