MS-II Saint Alphonsus Medical Group, Neurosurgery, Boise, ID, Idaho College of Osteopathic Medicine, Meridian ID Meridian, Idaho, United States
Introduction: Cavernous Carotid Aneurysms (CCAs) are rare entities and when present are typically asymptomatic and are generally considered benign. Even when symptomatic, they present with ipsilateral lateral rectus or oculomotor palsy. We report a rare case of a giant right CCA presenting with contralateral frozen eye and ipsilateral lateral rectus palsy treated via an expanded, endoscopic endonasal transsphenoidal approach and clipping. To our knowledge, this is the first report of this presentation and subsequent treatment strategy.
Methods: Clipping was chosen after the patient was found to be non-compliant with pre-therapy for a possible flow diversion. Additionally, a balloon occlusion test generated eye symptoms in the previously healthy right eye. This test along with the non-compliance with dual-anti-platelet (DAPT) therapy led to the decision to pursue direct aneurysm repair.
Results: A 59 year old female patient with a history of being a 3-pack a day smoker presented with contralateral frozen eye and ipsilateral lateral rectus palsy. CTA discovered a 3.5 x 1.7 x 2.2 cm giant right CCA that filled the cavernous sinus. After decision-making, surgery proceeded with patency checked intraoperatively via Doppler Ultrasound and post-operatively via CTA. Post-operatively patient reported improvement in right eye vision and was found to be non-compliant with non-smoking orders. 3-weeks post-op, patient suffered a massive carotid blowout in the para-clival region. This presented atypically as hematemesis due to the sphenoid resection which was initially diagnosed as a GI bleed and delayed notification of Neurosurgery till post-mortem. The carotid at the level of the aneurysm clipping was found to be patent post-mortem.
Conclusion : This case serves as an example of an unique approach and utility of an endoscopic endonasal approach to a rare case of a giant CCA causing contralateral eye symptoms. However, it also displays an atypical presentation of a carotid blowout as a result of the transsphenoidal approach.
