Bilateral intracavernous carotid artery aneurysms presenting as progressive cranial nerve palsies

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Bilateral intracavernous carotid artery aneurysms presenting as progressive cranial nerve palsies
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  © 2006 The Authors Journal compilation © 2007 Optometrists Association AustraliaClinical and Experimental Optometry 90.3 May 2007 207 CLINICAL AND EXPERIMENTAL OPTOMETRY  Clin Exp Optom   2007; 90: 3: 207–208DOI:10.1111/j.1444-0938.2006.00101.xKey words: cranial nerve palsies, intracavernous carotid artery aneurysm, magnetic resonance imagingThe presence of bilateral intracavernouscarotid artery aneurysms is rare 1  with few cases reported in the literature. Wepresent such a case, which initially mim-icked an isolated ischaemic sixth nervepalsy. CASE REPORT  An 85-year-old woman with a history of left sixth nerve palsy, which was symp-tomatically well controlled with Fresnelprisms, was reviewed in the eye clinic with an acute worsening diplopia. Neuro-logical examination showed left fourthnerve and longstanding sixth nerve pal-sies. Ophthalmic examination of anteriorand posterior segment was normal withno proptosis. In view of the clinical find-ings, magnetic resonance imaging of thebrain was undertaken. Axial T1 and T2 weighted images demonstrated bilateralintracavernous carotid artery aneurysms,measuring approximately 20 mm in dia-meter on right and 27 mm on the left (Fig. 1). Both aneurysms containedthrombus but demonstrated flow voidsindicating patency. The patient’s wors-ened diplopia was treated with occlusionof the left eye. She is being followed inthe eye clinic to monitor any signs of enlargement of the aneurysms. A possi-ble complication is rupture of an aneu-rysm, which can lead to formation of acarotico-cavernous fistula, but rarely tosubarachnoid haemorrhage due to theextradural position of the aneurysm. 8 Endovascular aneurysm occlusion is thecurrent treatment of choice as the aneu-rysms are inaccessible for surgery. 3,8  Dueto her age, no surgical or other interven-tion was considered appropriate. DISCUSSION Intracavernous carotid artery aneurysmsconstitute three to five per cent of allintracranial aneurysms. 1,2  They tend topresent in the elderly and show a femalepredominance. 1,3  Associated factors in-clude hypertension, trauma and connec-tive tissue disease. 1,3  Bilateral aneurysmsare rare. 1–3  Causative factors include radio-therapy, 4  systemic mycosis 5  and fibro-muscular dysplasia. 6  Our case was not associated with any of these conditions. A possible explanation is age-related weak-  Ali A    Bodla   MD Mark    Ablett   FRCR FRCP (Glas)  Andrew    Inglis  FRCOphthEye Unit, The Ayr Hospital, Ayr, Scotland, United KingdomE-mail: alibodla@aol.comBilateral intracavernous carotid artery aneurysms are rare and can present with different clinical findings. We report such a case presenting with progressive cranial nerve palsiesdue to gradual increase in the size of aneurysms. This case demonstrates the clinician’sdifficulty in diagnosis when isolated cranial nerve palsy is the sole presenting sign. Bilateral intracavernous carotid artery aneurysms presenting as progressive cranial nerve palsies Submitted: 7 May 2006Revised: 26 August 2006 Accepted for publication: 28 August 2006  Bilateral intracavernous carotid artery aneurysms Bodla, Ablett and Inglis  Clinical and Experimental Optometry 90.3 May 2007 208 © 2006 The Authors Journal compilation © 2007 Optometrists Association Australia ening of the internal carotid arterial wallinducing aneurysm formation. 1  After the initial examination, a diagno-sis of ischaemic sixth nerve palsy wasmade due to the patient’s age and theabsence of other focal neurological defi-cits. It was only the late onset fourthnerve palsy that led to reconsideration of the diagnosis. The differential diagnosesincluded cluster headache, trigeminalneuralgia, cavernous sinus malignancy,pituitary tumour and ocular myastheniagravis necessitating radiological imag-ing. 1,3  A thrombosed intracavernouscarotid artery aneurysm can mimic a neo-plastic lesion due to the absence of a flow  void. 7  Gradual asymmetrical increase inthe size of such aneurysms has beendescribed in the literature. 1  In our case,the aneurysm on the left was larger andthis is likely to explain the left-sided cra-nial nerve involvement. CONCLUSION This case illustrates a rare cause 1–3  of anisolated cranial nerve palsy. It should beremembered in differential diagnosis of progressive cranial nerve palsies. Due tothe patient’s age and the fact that com-plete occlusion of aneurysms over 10 mmin diameter is achieved in only 40 per cent of cases, 8  the decision was made not totreat the aneurysms. REFERENCES 1.Matsumoto K  , Kato A  , Fujii K  , Fujinaka T , Fukuhara R. Bilateral giant intracavernouscarotid aneurysm mimicking a cavernoussinus neoplasm—case report. Neurol Med Chir (Tokyo)   1996; 36: 583–585.2.Thiebot J. Bilateral giant aneurysm of thecarotid siphon. Ann Radiol (Paris)   1991; 34:142–145.3.Atri A  , Sheen V. Cavernous sinus syndromeand headache due to bilateral carotid artery aneurysm. Arch Neurol   2003; 60: 1327–1328.4.McConachie NS ,  Jacobson I. Bilateral aneu-rysms of the cavernous internal carotidarteries following yttrium-90 implantation. Neuroradiology   1994; 36: 611–613.5.Eguchi T , Nagakomi T , Teraoka A. Treat-ment of bilateral mycotic intracavernouscarotid aneurysm. Case report.  J Neurosurg  1982; 56: 443–447.6.Rebollo M , Quintana F , Cumbarros O , Ber-ciano J. Giant aneurysm of the intracavern-ous carotid artery and bilateral carotidfibromuscular dysplasia.  J Neurol Neurosurg Psychiatry   1983; 46: 284–285.7.Byrd SE , Bentson JR  ,  Winter J ,  Wilson GH ,  Joyce PW  , O’Connor L. Giant intracranialaneurysms stimulating brain neoplasm oncomputed tomography.  J Comput Assist Tomogr   1978; 2: 303–307.8.Kupersmith MJ , Berenstein A  , Choi IS , Ran-sohoff J , Flamm ES. Percutaneous transvas-cular treatment of giant intracavernousaneurysm. Neurology   1984; 34: 328–335. Corresponding author: Ali A BodlaEye Unit The Ayr Hospital AyrScotlandUNITED KINGDOME-mail: alibodla@aol.com Figure 1.T2-weighted axial MR image showing bilateralintracavernous carotid aneurysms (arrows)
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