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Isolated Trochlear Nerve Palsy Associated with Carotid-Cavernous Sinus Fistula: A Case Report
頸動脈－海綿竇瘻管導致滑車神經麻痺－病例報告
摘要
目的：提出頸動脈－海綿竇瘦管造成單獨的第四對顱神經麻痺病例。 方法：病例報告。 結果：一位六十七歲女性因頭痛及複視前來求診，經眼科檢查發現是單獨的右眼上斜肌麻痺，其他眼睛部位檢查並無異常。神經內科及放射科安排的核磁共振及血管攝影檢查發現是頸動脈－海綿竇瘻管造成的單一第四對顱神經麻痺。在接受經動脈血管栓塞治療後，病患複視情況已大為改善。經追蹤八個月後已恢復正常。 結論：頸動脈－海綿竇瘻管依其血循動力學可分為前分流州變分流。前分流至上眼靜脈通常造成紅眼及眼球突出，臨床上以此型態為顯而常見；然而後分流侷限在海綿竇內，通常會合併或單獨影響第三，四，六對腦神經；其中以第三及第六對腦神經麻痺較常見。海綿竇區病灶引起單獨的滑車神經麻痺雖曾被報告但是並不常見。我們報告這一病例，希望臨床醫師在遇到第四對腦神經麻痺時，能把海綿竇病變列入鑑別診斷。
關鍵字
無資料並列摘要
Purpose: To report a case of isolated trochlear nerve palsy caused by carotid-cavernous sinus fistula. Method: A case report. Result: A 67-year-old woman suffered from intermittent thunderclap headache and acute onset of vertical diplopia when in left gaze and right-head tilt. Routine ocular examinations were unremarkable with the exception that the three-step test revealed right superior oblique muscle palsy. A brain magnetic resonance imaging and artery series (MRI/MRA) revealed a carotid-cavernous sinus fistula in the right cavernous sinus. Conventional cerebral angiography confirmed that the lesion was fed by meningeal branches of the internal carotid artery with flow posteriorly to the inferior petrosal sinus, and then to the internal jugular vein. Trans-arterial embolization (TAE) was performed, and a Guglielmi Detachable Coil (GDC) placed. The vertical diplopia resolved significantly after TAE but pulsatile tinnitus remained. Conclusion: Ocular motor nerves palsy associated with a cavernous sinus lesion usually involves the third, fourth, and sixth cranial nerves. Isolated the fourth nerve palsy caused by carotid-cavernous sinus fistula (CCSF) is uncommon. In this case, we propose the following: (1) Thunderclap-type headache could appear as a first symptom in CCSF. (2) Isolated trochlear nerve palsy due to the cavernous sinus lesion is uncommon, clinicians should be alert of its possibility.
延伸閱讀
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