Unilateral Oculomotor Nerve Palsy from Chronic Subdural Hematoma: Case report and Review of the Literature
Zigouris Andreas* and Voulgaris Spyridon
Department of Neurosurgery, University Hospital of Ioannina, Greece
Submission: September 23, 2016; Published: November 09, 2016
*Corresponding author: TZigouris Andreas, Department of Neurosurgery, University Hospital of Ioannina, Greece, Tel: 302651099701; Email;email@example.com
How to cite this article: Zigouris A, Voulgaris S. Unilateral Oculomotor Nerve Palsy from Chronic Subdural Hematoma: Case report and Review of the Literature. Open Access J Neurol Neurosurg. 2016; 1(5): 555571. DOI: 10.19080/OAJNN.2016.01.555571
Chronic subdural hematoma with isolated 3rd cranial nerve palsy was detected in a patient who received an antiplatelet agent. He was operated and after surgery had an immediate resolution of palsy. The proposed mechanism of the reversible 3rd nerve palsy was a compression to the left uncus and moreover a microvascular infarction of the nerve due to mechanical reason, that is rarely observed in this type of intracranial hematomas.
Chronic subdural hematoma is a common result after a mild to moderate head injury, especially in elderly who received anticoagulant agents [1,2]. There is a broad spectrum of signs and symptoms, from a mild headache, hemiparesis to comatose patient. Cranial nerve palsies from a chSDH as initial symptoms are uncommon. Pupil-sparing oculomotor nerve palsy with chSDH was described first time from Crone KR et al in a patient with adult-onset diabetes mellitus . Isolated 3rd cranial nerve palsy from bilateral chSDH was first published from Phookan et al, who described an immediate resolution of palsy after surgery (4). In our study we report a bilateral chSDH which caused a unilateral oculomotor palsy in a patient who received an ant platelet agent.
An 83-year old man with a recent history of anti platelet agent administration suffered from a mild headache after a minor head injury two months before. The last two days his daughter observed a left ptosis and a progressive left hemi paresis. He came to our hospital, where the neurologic examination included GCS: 15, 4/5 left hemi paresis and a leftptosis with a slight anisocoria. The CT scan showed a bilateral chronic subdural hematoma (chSDH) (Figure 1). He underwent an urgent evacuation of hematomas through 4 burr holes, frontal
and parietal under general anesthesia. Hematomas had a very high pressure. We inserted bilaterally from parietal burr holes two drainages, which were removed after 48 hours. The ptosis and the hemi paresis resolved immediately, 12 hours after surgery. The proposed mechanism of the reversible 3rd nerve palsy was a compression to the left uncus and moreover to the left oculomotor nerve in the ambient cistern. The patient left our department after 2 days and he returned to his normal life and activities without any neurological deficit.
chSDH in elderly is the most common hematoma after
a head injury, especially in case who received any form of
anticoagulants. Bilateral chSDH create a new intracranial
environment, where there exists a different balance, which is
more fragile. The time of disturbance causes various symptoms
and signs. A unique feature is unilateral 3rd cranial nerve palsy.
According to this clinical entity a few cases of oculomotor
palsy as an initial symptom of a chSDH was published the last
30 years [3-5]. The herniation of uncus in cases of intracranial
hypertension compress directly the oculomotor nerve and
mesencephalic structures, resumed to anisocoria and coma.
The differential diagnosis of a conscious patient with anisocoria
includes diabetes mellitus, hypertension, atherosclerosis,
collagen vascular disease, intracranial aneurysm, particularly of
the posterior communicating artery, cavernous sinus thrombosis
[4-8]. The mechanism in all cases is microvascular infarction of
the nerve due to a mechanical or pathological reason.