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Show J. Clill. Nellro-ophthalmol. 4: 221-223, 1984. Ophthalmoplegic Migraine with Proximal Posterior Cerebral Artery Vascular Anomaly RICHARD K. IMES, M.D. MARIO L. R. MONTEIRO, M.D.* WILLIAM F. HOYT, M.D. Abstract We report herein the unique finding of a small perimesencephalic vascular anomaly in a patient with a partial oculomotor nerve palsy and a 25-year history of recurrent ophthalmoplegic migraine. Case Report A 31-year-old man was seen in the neuroophthalmology unit of the University of California, San Francisco, for evaluation of a partial right third nerve palsy. He had a right exotropia and hypotropia with 4 mm of ptosis, inability to elevate or depress the eye, and poor adduction. The right pupil was 3 mm in diameter and unreactive. There was no evidence of aberrant regeneration. The left eye was normal. At age 5, he had a severe headache with nausea and vomiting, drooping of his right upper lid, and impaired movement of the right eye. The palsy cleared within 2 weeks. He has since had 60-70 similar episodes; the most recent occurring 1 year ago. The headache is always right-sided, lasting as long as 5 days. He describes the pain as severe, constant, and sharp. Nausea and a "strong and sour" smell to food occurs 2 hours before the headache begins. Vomiting and a puffy, watery feeling of the right eye precedes the oculomotor nerve palsy. Recovery takes 1-2 weeks. Initially, there was a total recovery of lid and eye movement. However since age 7, he has had residual oculomotor paresis. This deficit has increased with subsequent attacks. There is no family history of migraine. Computed tomography showed a contrast enhancing lesion on the right side, anterior to the From the Neuro-ophthalmology Unit, Departments of Neurological Surgery, Neurolugy, and Ophthalmulugy. the University of California Medical Center, San Franciscu, California. • Present address: Department of Ophthalmology, the University of Sao Paulo Medical Sehoul. Sao Paulo, Brazil. December 1984 Figure I. Postcontrast axial CT showing enhancing lesion anterior to the brain stern (arrow). midbrain and pons (Fig. 1). Cerebral arteriography demonstrated a vascular anomaly involving the peduncular and ambient segment of the right posterior cerebral artery that filled from both the basilar artery (Fig. 2) and from the right internal carotid artery through a large posterior communicating artery (Fig. 3). Discussion Angiographic studies in patients with ophthalmoplegic migraine usually show normal findings. 221 Ophthalmoplegic Migraine Figure 2. Post..rior ant..riL)r ,'i..w of wrtebral art..riogram showing vascular anomalv (arrow) of the p..duncular and ambi..nl s..gments of right posterior cerebral arten', Figure 3. Lateral view l,i right internal carotid arteriogram showing filling of th.. vascular anomalv through thl' large pllst..ril)r communicating arlen', 222 Journal of Clinical Neuro-ophthalmology Walsh and O'Doherty,! and Bickerstaf£2 reported patients with narrowing of the carotid artery in the cavernous sinus. Friedman et al.) reported one patient with segmental narrowing of the basilar artery. Our patient's posterior cerebral artery vascular anomaly occupies the zone traversed by his oculomotor nerve. We believe the chronic paresis of his nerve is directly related to the vascular anomaly, but do not know how the paresis is aggravated by his migraine headaches. December 1984 Imes, Monteiro, Hoyt References 1. Walsh, )., and O'Doherty,S.: A possible explanation of the mechanism of ophthalmoplegic migraine. Neurology 10: 1079-1084, 1960. 2. Bickerstaff, E.: Ophthalmoplegic migraine. Rev. Neurol. 110: 582-588, 1964. 3. Friedman, A., Harter, D., and Merritt, H.: Ophthalmoplegic migraine. Arch. Neurol. 7: 320-327, 1962. Write for reprilllS 10.' William F. Hoyt, M.D., 782M, University of California at San Francisco, San Francisco, California 94143. 223 |
