Oculomotor Nerve Palsy Secondary to Posterior Communicating Artery Aneurysm: A Narrative Review and Proposed Treatment Algorithm.

Abstract

Background: Oculomotor nerve palsy (ONP) is a condition characterized by ptosis, restricted eye movement, and pupillary abnormalities, with causes ranging from congenital to acquired factors. Among these, posterior communicating artery aneurysm (PcomA) represents the most clinically urgent due to the risk of rupture. Despite its significance, no standardized treatment guidelines currently exist. This narrative review aims to summarize current treatment approaches and provide a decision-making framework for clinicians.

Methods: A literature review was conducted using Web of Science and PubMed from inception to December 30, 2024, with additional sources identified via manual reference searches.

Results: Both aneurysm clipping and endovascular therapy are effective for treating PcomA-induced ONP. Endovascular techniques include coil embolization, stent- or balloon-assisted coiling, flow diverter placement, and intrasaccular flow disruption device placement. Surgical clipping is preferred in younger patients (under 60 years old), those with ONP symptoms longer than 7 days, an aneurysm size ≥7 mm, or complete ONP. In contrast, endovascular therapy is recommended for older patients, those in poor health, or undergoing treatment with antithrombotic agents. Emerging evidence suggests flow diverter placement is a promising direction, though further research is warranted.

Conclusion: This review proposes a therapeutic algorithm to aid in clinical decision-making. The choice between aneurysm clipping and endovascular therapy should be individualized, taking into account patient-specific clinical factors.