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March 31, 2020; 94 (13) Resident & Fellow Section

Teaching NeuroImages: Pupil-sparing compression of oculomotor nerve by posterior cerebral artery vessel

Anfei Li, Anika Tandon, Apostolos J. Tsiouris, Marc J. Dinkin, Cristiano Oliveira
First published March 9, 2020, DOI: https://doi.org/10.1212/WNL.0000000000009181
Anfei Li
From the Division of Neuro-Ophthalmology (A.T., M.J.D., C.O.), Department of Ophthalmology, and Department of Radiology (A.J.T.), Weill Cornell Medicine (A.L.), New York, NY.
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Anika Tandon
From the Division of Neuro-Ophthalmology (A.T., M.J.D., C.O.), Department of Ophthalmology, and Department of Radiology (A.J.T.), Weill Cornell Medicine (A.L.), New York, NY.
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Apostolos J. Tsiouris
From the Division of Neuro-Ophthalmology (A.T., M.J.D., C.O.), Department of Ophthalmology, and Department of Radiology (A.J.T.), Weill Cornell Medicine (A.L.), New York, NY.
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Marc J. Dinkin
From the Division of Neuro-Ophthalmology (A.T., M.J.D., C.O.), Department of Ophthalmology, and Department of Radiology (A.J.T.), Weill Cornell Medicine (A.L.), New York, NY.
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Cristiano Oliveira
From the Division of Neuro-Ophthalmology (A.T., M.J.D., C.O.), Department of Ophthalmology, and Department of Radiology (A.J.T.), Weill Cornell Medicine (A.L.), New York, NY.
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Teaching NeuroImages: Pupil-sparing compression of oculomotor nerve by posterior cerebral artery vessel
Anfei Li, Anika Tandon, Apostolos J. Tsiouris, Marc J. Dinkin, Cristiano Oliveira
Neurology Mar 2020, 94 (13) e1450-e1451; DOI: 10.1212/WNL.0000000000009181

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A 54-year-old woman presented with a 30-year history of worsening left blepharoptosis. Neuro-ophthalmic examination was significant for blepharoptosis, limited levator function, and supraduction in the left eye with left hypotropia, and normal pupils without diplopia. MRI brain/orbits revealed subtle atrophy of the left superior rectus (figure 1, A and B), without any orbital pathology. Superior compression of the left oculomotor nerve by the posterior cerebral artery (PCA) was observed (figure 1, C–E). Given the microanatomy of oculomotor nerve in the cistern space,1,2 this is a rare selective compression of the superolateral oculomotor nerve by the PCA vessel (figure 2), sparing the superomedial parasympathetic limb.

Figure 1
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Figure 1 Compression of the left CNIII nerve by left posterior cerebral artery

(A, B) Isolated asymmetric atrophy of the left superior rectus muscle (arrows). (C) Left posterior cerebral artery in cross-section (arrow) impinges upon the left CNIII (arrowhead). (D, E) Asymmetric flattening of the left CNIII (arrowheads) by the left posterior cerebral artery (arrows).

Figure 2
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Figure 2 Illustration of the CNIII microanatomy (not to scale)

Image is constructed based on similar images in Brazis.3

Study funding

No targeted funding reported.

Disclosure

The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

Appendix Authors

Table1

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Teaching slides links.lww.com/WNL/B67

  • © 2020 American Academy of Neurology

References

  1. 1.↵
    1. Miyazaki S
    . Location of motoneurons in the oculomotor nucleus and the course of their axons in the oculomotor nerve. Brain Res 1985;348:57–63.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Atasever A,
    2. Durgun B,
    3. Celik HH,
    4. Yilmaz E
    . Somatotopic organization of the axons innervating the superior rectus muscle in the oculomotor nerve of the rat. Cells Tissues Organs 1993;146:251–254.
    OpenUrl
  3. 3.↵
    1. Brazis PW
    . Localization of lesions of the oculomotor nerve: recent concepts. Mayo Clin Proc 1991;66;1029–1035. Review.
    OpenUrlCrossRefPubMed

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