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Show Journal of Clinical Neurcruphllullmology 10( 2): 157- 158, 1990. Neuro- ophthalmic Feature Photo © 1990 Raven Press, Ltd., New York Subarachnoid Hemorrhage During Computed Tomography from Presumed Aneurysm in a Case of Painless Oculomotor Palsy Michael L. Slavin, M. D. The acute onset of isolated third nerve palsy with pupil involvement is due to expansion or perforation of an intracranial aneurysm, most often the posterior communicating artery ( less commonly the basilar artery), until proven otherwise. Although headache or ipsilateral ocular discomfort is invariably present in such cases, a minority present as a painless ophthalmoplegia and blepharoptosis. Indeed, all 174 patients with third nerve palsy and posterior communicating artery aneurysms ( age 14- 81, mean 50.6) reported by Soni ( 1) were stated to have associated pain. The following patient with a flu- like illness presented with a painless complete oculomotor palsy presumably due to an aneurysm. CASE REPORT A 30- year- old normotensive woman suffered from upper respiratory infection and low grade fever for 2 weeks, along with several of her children. During the course of the coryza she noted diplopia From the Division of Neuro- ophthalmology, Department of Ophthalmology, Long Island Jewish Medical Center, Long Island Campus, Albert Einstein College of Medicine, New Hyde Park, New York. Address correspondence and reprint requests to Dr. Michael Slavin, Long Island Jewish Medical Center, Department of Ophthalmology, New Hyde Park, NY 11041, U. S. A. 157 followed by complete blepharoptosis of the right upper lid. There was no periocular discomfort, headache, neck rigidity, or other neurologic symptoms. Neuro- ophthalmologic examination was normal except for the presence of a complete right third nerve palsy including the pupil. An emergency computed tomography ( CT) was performed as a prelude to four- vessel intracranial arteriography. The noncontrast study ( Fig. lA on p. 158) was unremarkable. Soon after the intravenous injection of contrast agent ( 50 ml bolus of Conray 60%, followed by 100 ml infusion), however, the patient reported a severe headache. CT sections were completed and showed evidence of subarachnoid hemorrhage with fresh blood outlining the basal cisterns ( Fig. IB on p. 158). The patient became unresponsive with progressive neurologic deterioration, and died 2 weeks later. An angiogram was not perfonned to document the source of the intracranial bleed, which was most likely a right internal carotid- posterior communicating artery aneurysm. This case reminds the ophthalmologist, neurologist, and neuro- ophthalmologist that acute oculomotor palsy even without pain may be a sign of aneurysm. REFERENCE 1. Som SR. Aneurysms of the posterior communicating artery and oculomotor pareses. J Neurol Neurosurg Psychiatry 1974; 37: 475- 84. 158 M. L. SLAVIN FIG. 1. Noncontrast computed axial tomography ( A) at the level of the supra- sellar cistern shows no abnormalities. Several minutes later, however, after the injection of intravenous contrast, similar sections show the presence of subarachnoid hemorrhage within the basal cisterns ( B). The probable site of aneurysm is shown ( arrows). |
