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Headache, Facial Palsy, and Diplopia: an Unusual Presentation of Ruptured Distal Anterior Cerebral Artery Aneurysm

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Headache, Facial Palsy, and Diplopia: an Unusual Presentation of Ruptured Distal Anterior Cerebral Artery Aneurysm Published online: 2019-09-03 Letters to the Editor Second, it would be also appropriate to seek out other 3. Kar PS, Ogoe B, Poole R, Meeking D. Di-George syndrome causes for the studied patient, including mitochondrial presenting with hypocalcaemia in adulthood: Two case reports and a review. J Clin Pathol 2005;58:655-7. disorders (several of these associated with parathyroid 4. Goldmuntz E. DiGeorge syndrome: New insights. Clin Perinatol dysfunction) or mutations in the calcium-sensing receptor. 2005;32:963-78. Financial support and sponsorship 5. Simão I, Lourenço T, Lopes L, Ramos MP. First seizure as late presentation of velo-cardio-facial syndrome. J Pediatr Endocrinol Nil. Metab 2013;26:381-3. Conflicts of interest This is an open access article distributed under the terms of the Creative Commons There are no conflicts of interest. Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new Mahmood Dhahir Al‑Mendalawi creations are licensed under the identical terms. Department of Paediatrics, Al-Kindy College of Medicine, Baghdad University, Baghdad, Iraq Access this article online Quick Response Code: Address for correspondence: Prof. Mahmood Dhahir Website: Al-Mendalawi, www.ruralneuropractice.com P. O. Box: 55302, Baghdad Post Office, Baghdad, Iraq. E-mail: [email protected] DOI: References 10.4103/jnrp.jnrp_510_16 1. Gkampeta A, Kouma E, Touliopoulou A, Aggelopoulos E, Vourti E. Afebrile seizures as initial symptom of hypocalcemia secondary to hypoparathyroidism. J Neurosci Rural Pract 2016;7 Suppl 1:S117-9. How to cite this article: Al-Mendalawi MD. Afebrile seizures as initial symptom of hypocalcemia secondary to hypoparathyroidism. J Neurosci 2. Graesdal A, Surén P, Vadstrup S. DiGeorge syndrome. An Rural Pract 2017;8:486-7. underdiagnosed disease category with different clinical features. Tidsskr Nor Laegeforen 2001;121:3177-9. © 2017 Journal of Neurosciences in Rural Practice | Published by Wolters Kluwer - Medknow Headache, Facial Palsy, and Diplopia: An Unusual Presentation of Ruptured Distal Anterior Cerebral Artery Aneurysm Sir, vascular pathology, she was referred to our center. Intracerebral aneurysms may present with cranial At presentation, she was conscious, alert without any nerve paresis in more than 20% cases. Nerve fibers focal motor power deficit. However, she had right may be compressed mechanically by the aneurysm sixth nerve and lower motor neuron type seventh nerve sac or by the bleed from the ruptured aneurysm.[1] palsy (House and Brackmann grade IV) [Figure 1d]. On However, the involvement of cranial nerves far away CT angiography, there was a saccular aneurysm at the from the ruptured aneurysm is unusual. Here, we are junction of pericallosal and callosomarginal artery on the discussing a case with unilateral sixth and seventh left side [Figure 1c]. She underwent bifrontal craniotomy nerve palsy following ruptured distal anterior cerebral with clipping of the aneurysm. The perioperative period artery aneurysm who clinically improved after was uneventful. The right seventh nerve palsy improved surgery. completely at 3-month follow-up with partial recovery of the sixth nerve [Figure 1e]. A 30-year-old lady presented with a history of sudden onset headache and right side facial weakness. Initially, Cranial nerve involvement in cases of subarachnoid she was treated by a local physician with the diagnosis hemorrhage is commonly due to the mechanical of stroke. There was no other comorbid illness. The day pressure by the aneurysm. Unilateral oculomotor nerve after the event, she had developed diplopia on looking palsy due to mechanical compression by posterior toward the right side. Initial computed tomography (CT) communicating-internal carotid artery aneurysm has been scan showed intraventricular hemorrhage, anterior described in literature.[2] The oculomotor nerve palsy has interhemispheric bleed with perimesencephalic variable outcome with clipping and coiling and at times, hemorrhage [Figure 1a and b]. In suspicion of some the recovery may not be complete.[2,3] Lower motor neuron Journal of Neurosciences in Rural Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2017 487 Letters to the Editor given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship a b c Nil. Conflicts of interest There are no conflicts of interest. Sushant Sahoo, Chhitij Srivastava Department of Neurosurgery, KGMU, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Sushant Sahoo, e d Department of Neurosurgery, KGMU, Lucknow, Figure 1: (a and b) Noncontrast computed tomography scan showing Uttar Pradesh, India. anterior interhemispheric bleed, intraventricular hemorrhage. Note the E-mail: [email protected] blood in the right cisternal space (red arrows). (c) Computed tomography angio showing the saccular aneurysm (blue arrow) at the junction of pericallosal and callosomarginal artery. (d) Preoperative patient image References showing right-sided facial palsy. (e) Postoperative patient image showing 1. Kurokawa R, Saito R, Nakamura Y, Kagami H, Ichikizaki K. the improvement of right-sided facial palsy Ruptured vertebral artery-posterior inferior cerebellar artery aneurysm associated with facial nerve paresis successfully type facial nerve involvement found with anterior inferior treated with interlocking detachable coils – Case report. Neurol cerebellar artery and vertebral artery-posterior inferior Med Chir (Tokyo) 1999;39:863-6. cerebellar artery aneurysm. Cases of nonaneurismal 2. Chalouhi N, Theofanis T, Jabbour P, Dumont AS, Gonzalez LF, Starke RM, et al. Endovascular treatment of posterior perimesencephalic cistern hematoma presenting with third communicating artery aneurysms with oculomotor nerve palsy: nerve palsy have also been reported.[4] Clinical outcomes and predictors of nerve recovery. AJNR Am J Neuroradiol 2013;34:828-32. Sudden onset facial palsy with headache in this case was 3. Gaberel T, Borha A, di Palma C, Emery E. Clipping versus initially considered as stroke. However, the persistence coiling in the management of posterior communicating artery of headache and evolution of newer symptom (diplopia) aneurysms with third nerve palsy: A systematic review and mandate further evaluation. Blood in the right basal meta-analysis. World Neurosurg 2016;87:498-506.e4. cistern space has caused direct compression over the 4. Sadamasa N, Sano N, Takeda N, Yoshida K, Narumi O, right sixth and seventh nerve fibers. The additional Chin M, et al. Perimesencephalic nonaneurysmal subarachnoid hemorrhage with unilateral third cranial nerve palsy: Two case mechanism of vasospasm of the arterial supply to the reports. Neurol Med Chir (Tokyo) 2012;52:918-20. nerve nuclei may perhaps explain the same.[4] In this case, both facial palsy and diplopia improved with time. This is an open access article distributed under the terms of the Creative Commons However, direct compression of the nerve fibers by the Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new aneurysmal sac has varied outcome as seen with third creations are licensed under the identical terms. nerve palsy in cases of posterior communicating-internal carotid artery aneurysms. The degree of initial Access this article online nerve palsy, the size of aneurysm, time, and type of Quick Response Code: [3] Website: intervention may influence the outcome. The present www.ruralneuropractice.com case supports that cranial nerve palsy may occur purely due to cisternal hemorrhage away from the ruptured DOI: aneurysm. The cisternal blood usually get resolves with 10.4103/jnrp.jnrp_467_16 time so also the vasospasm involving the arterial supply to the brainstem. This possibly explains the benign nature of this cranial nerve paresis in such cases. How to cite this article: Sahoo S, Srivastava C. Headache, facial palsy and Declaration of patient consent diplopia: An unusual presentation of ruptured distal anterior cerebral The authors certify that they have obtained all appropriate artery aneurysm. J Neurosci Rural Pract 2017;8:487-8. patient consent forms. In the form the patient(s) has/have © 2017 Journal of Neurosciences in Rural Practice | Published by Wolters Kluwer - Medknow 488 Journal of Neurosciences in Rural Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2017.
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