Campos Cynthia Resende, Massaro Ayrton Roberto, Scaff Milberto
Department of Neurology, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil.
Arq Neuropsiquiatr. 2003 Sep;61(3A):668-70. doi: 10.1590/s0004-282x2003000400027. Epub 2003 Sep 16.
Partial oculosympathetic palsy followed by ischemic manifestations in brain or retina are the main symptoms of extracranial internal carotid artery (ICA) dissection. Unusually, cranial nerves may be affected. Isolated oculomotor nerve palsy is found only rarely.
We present a 50-year-old nondiabetic man who experienced acute onset of right occipital headache which spread to the right retro-orbital region. Five days later he noticed diplopia and right blurred vision sensation. Neurologic examination disclosed only impaired adduction and upward gaze of right eye, slight ipsilateral pupillary dilatation, without ptosis. Brain MRI was normal. Angiography showed right internal carotid artery dissection with forward occlusion to the base of the skull. Intravenous heparin followed by warfarin was prescribed. The headache and the oculomotor nerve deficit gradually resolved in the next three weeks.
Isolated oculomotor nerve palsy is underrecognized as a clinical presentation of extracranial ICA dissection. If the angiographic evaluation is incomplete without careful study of extracranial arteries, misdiagnosis may lead to failure to initiate early treatment to prevent thromboembolic complications. For this reason we draw attention to the need for careful evaluation of cervical arteries in patients with oculomotor nerve palsy. Mechanical compression or stretching of the third nerve are possible mechanisms, but the direct impairment of the blood supply to the third nerve seems to be the most plausible explanation.
部分眼交感神经麻痹，随后出现脑部或视网膜的缺血表现，是颅外颈内动脉（ICA）夹层的主要症状。不常见的是，颅神经可能会受到影响。孤立性动眼神经麻痹仅罕见发生。
我们报告一名50岁非糖尿病男性，他突发右枕部头痛，并蔓延至右眶后区域。五天后，他注意到复视和右眼视力模糊感。神经系统检查仅发现右眼内收和上视受损，同侧瞳孔轻度散大，无眼睑下垂。脑部MRI正常。血管造影显示右颈内动脉夹层，向前闭塞至颅底。给予静脉注射肝素，随后口服华法林。头痛和动眼神经功能缺损在接下来的三周内逐渐缓解。
孤立性动眼神经麻痹作为颅外ICA夹层的临床表现未得到充分认识。如果血管造影评估不完整，未仔细研究颅外动脉，误诊可能导致未能早期启动治疗以预防血栓栓塞并发症。因此，我们提请注意对动眼神经麻痹患者的颈动脉进行仔细评估的必要性。动眼神经受到机械压迫或牵拉是可能的机制，但动眼神经血供的直接受损似乎是最合理的解释。
