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Show ,~> 1992 Raven Press, Ltd., New York Aneurysmal Oculomotor Nerve Palsy in an 11- Year- Old Boy Mitchell Jay Wolin, M, D, and Richard A, Saunders, M. D. Cerebral aneurysms are rare in children. When they occur, they usually present with a history of subarachnoid hemorrhage. Gabianelli et al. ( 1) recently reported a 14year- old girl with an isolated oculomotor nerve palsy due to aneurysm. In their discussion, they state that arteriography is, " Unnecessary in patients under 10 ( years of age) if the symptoms and signs of subarachnoid hemorrhage are absent or high resolution computerized tomography scan or adequate magnetic resonance imaging scan is normaL" To date, their patient is the youngest reported in the literature with an isolated oculomotor nerve palsy proved to be caused by cerebral aneurysm. We report herein an ll- year- old boy who presented with an oculomotor nerve palsy due to aneurysm with minimal preceding symptoms and no other signs of intracranial disease. Key Words: Cerebral aneurysm- Third ( or oculomotor) nerve palsy in children. . From the Department of Ophthalmology ( M. j. W.). UniverSity of South Carolina School of Medicine, Columbia; Medical University of South Carolina ( R. A. s.), Charleston, South Carolina, U. s. A. Address correspondence and reprint requests to Dr. Mitchell jay Wolin, Department of Ophthalmology, 4 Richland Medical Park, Suite 300, University of South Carolina School of Medicine, Columbia, SC 29203, USA. 178 CASE REPORT An ll- year- old boy had diarrhea, which spontaneously resolved. Seven days later, he experienced dizziness and vertigo and reported ringing in both ears. Then mild ptosis appeared in his right upper eyelid, which was accompanied by pain in the right orbit. He also had nausea and vomiting, but this resolved within 3 days. However, his headache persisted, and he developed a right oculomotor nerve palsy. He was treated concurrently with oral penicillin for otitis media by another physician without improvement. Three weeks after the onset of symptoms, the patient was admitted to the hospital for evaluation. Examination at that time revealed an alert child with measured visual acuity, right eye 20/ 30, left eye 20/ 20. Visual fields by confrontation were normal. The right pupil measured 5 mm and was sluggishly reactive. The left pupil measured 3 mm and was briskly reactive. No afferent pupillary defects was detected. Motility examination revealed an exotropia and right hypertropia associated with incomplete right oculomotor nerve palsy ( Fig, 1). Neurological examination was otherwise normal and without evidence of meningeal irritation. Computed tomography of the head and orbits, with contrast and 5- mm axial sections, was performed the day after admission and was normaL with no focal mass effect or shift of the midline. Serial images through the orbit or sella showed no abnormality. The working diagnosis was ophthalmoplegic migraine. On the second hospital day, the patient developed nausea, vomiting, and complained of a throbbing right- sided headache. A lumbar puncture had an opening pressure of 120 cmH20, Examination of the cerebrospinal fluid revealed 75 red blood cells ANEURYSMAL JUVENILE THIRD NERVE PALSY 179 FIG. 1. Partial right 3rd nerve palsy in an 11- year- old boy. and 2 white blood cellsl1 cm, with 71 mg% glucose. Because of the abnormal cerebrospinal fluid, angiography was performed and revealed an aneurysm of the right internal carotid artery at the origin of the posterior communicating artery ( Fig. 2). The patient subsequently underwent surgery to clip the aneurysm. Postoperatively, visual acuity was 20/ 50 in the right eye. No afferent pupillary defect was noted. Repeat angiography 1 week postoperatively was indicative of a moderate degree of spasm of the internal carotid artery. Motility showed complete ptosis 00 with exotropia and hypotropia, showing complete paralysis of the 3rd cranial nerve. The patient was subsequently lost to follow- up. DISCUSSION Although the history given by this patient may have suggested subarachnoid hemorrhage, at the time of presentation, he was alert, oriented, and free of suspicious systemic signs or symptoms. The only important physical finding on ophthalmologic and neurologic examination was a right oculomotor 3rd nerve palsy. The mildly decreased acuity could be explained by lenticular aberration from a dilated pupil. One could argue, therefore, that this was an isolated cranial mononeuropathy. Most authors seem to use the term " isolated" to refer to limited signs and symptoms at the time of examination. Our patient would thus appear to fit into this category. His aneurysm was not detected on the computed tomography scan. This might have been because this older generation scan was done with 5- mm slices. However, conventional angiography is still necessary for aneurysm detection and delineation when this diagnosis is suspected ( 1). Miller ( 2) reports on 30 children with isolated oculomotor nerve palsy. Two patients ( ages 16 and 17) with aneurysms are described. Both had preceding symptomatology consisting of occipital and deep orbital headache, nausea, vomiting, and stiff neck. In an editorial on Gabianelli's recent FIG. 2. Angiography demonstrates an aneurysm of the right internal carotid artery at the origin of the posterior communicating artery ( arrow). 1 Clin Neuro- ophlhalmol, Vol. 12, No. 3, 1992 180 M. I. WOLIN AND R. A. SAUNDERS report, Fox ( 3) suggests that further unreported cases concerning this issue will be brought to light. At age 11 years, we believe ours to be the youngest patient reported to date with an essentially isolated 3rd nerve palsy due to a cerebral aneurysm. We therefore believe that age alone should not be considered a cutoff for the need for angiography in a patient with an otherwise isolated oculomotor nerve palsy. Angiography should be performed in any case where an aneurysm would otherwise be present in the differential diagnosis. REFERENCES 1. Gabianelli EB, Klingele IG, Burde RM. Acute oculomotor nerve palsy in childhood. I Clin Nellro- ophthalmol 1989; 9: 3~. 2. Miller NR. Solitary oculomotor nerve palsy in childhood. AmI Ophthalmol 1977; 83: 10&-- 11. 3. Fox A. Angiography for third nerve palsy in children. [ Editorial CommenLl1 Clin Nellro- ophthalmol 1989; 9: 37~. |
