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  • Resolution of Oculomotor Nerve Palsy Secondary to Ruptured Posterior Communicating Artery Aneurysms: Comparison Between Clipping and Coiling

    Final Number:

    D. Jay McCracken MD; Brendan Lovasik BS; Justin Caplan MD; Nefize Turan MD; Courtney McCracken PhD; Daniel Barrow MD; C. Michael Cawley MD, FACS; Jacques Dion MD; Rafael Tamargo MD; Raul Nogueira MD; Gustavo Pradilla MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Posterior communicating artery aneurysm (PCoA) induced oculomotor nerve palsy (ONP) in acute subarachnoid hemorrhage is a well-established entity. Previous studies have attempted to address the effectiveness of clip ligation or coil embolization on the rate and completeness of ONP resolution, but have been limited by small sample sizes.

    Methods: In this multi-centered study 55 patients with ruptured PCoA and acute ONP from January 1991 to October 2013 were reviewed. Included patients had angiographically confirmed PCoA following subarachnoid hemorrhage and complete or partial ONP on admission. Rate of resolution of ONP was determined from treatment date to last known follow-up and was defined as complete vs. partial or no resolution. Resolution data on 83 similarly treated patients was extracted from the literature and combined to increase sample size. Outcomes and treatment groups were directly compared.

    Results: A total of 138 patients (67 clipped and 71 coiled) presented with either complete (47%) or partial (53%) ONP. Patients undergoing clipping were more likely to have complete resolution of ONP compared to patients undergoing coiling (71.6% vs. 54.9%, respectively, OR=2.07, 95% CI (1.02 –4.21), p=0.042). Further comparison among the 55 patients in the primary data set showed there was no difference between time to complete resolution (153 vs. 230 days, p=0.214) (Figure 1), aneurysm size (7.3 ±2.5 vs. 6.8 ±2.2 mm, p=0.52), and median time from ONP onset to treatment (2 vs. 2 days, p=0.9) between the clipped and coiled groups, respectively.

    Conclusions: In our series of patients with ONP secondary to ruptured PCoA, patients undergoing clipping were more likely to experience complete resolution vs. coiling. There was no difference between the treatment groups with regard to aneurysm size, time from ONP onset to treatment, and rate of complete resolution. Larger multi-centered studies are needed to assess these treatments for ONP resolution with greater precision.

    Patient Care: 1) By understanding that all other variables being equal, patients who present with subarachnoid hemorrhage from a ruptured posterior communciating artery aneurysm and third nerve palsy should have more consideration given to clip ligation to insure that their cranial neuropathy will completely resolve over time

    Learning Objectives: 1) Understand the difference that coil embolization or clip ligation has on the resolution of third nerve palsy with acute posterior communicating artery aneurysms 2) Know that this is a rare occurrence that requires patients from multiple years and hospitals to accurately assess either treatment

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