A 73-year-old diabetic male presented with progressively worsening diplopia and difficulty reading for 2 months. He denied having any fever, trauma, headache, numbness or weakness of his extremities or changes in other senses. Vital signs, physical and neurological exams were unremarkable, except for diplopia on right lateral gaze with distance, but not on left lateral gaze. CT, CTA, and MRI of the brain were obtained in addition to a cerebral angiogram (Figures 1, 2, 3, 4 and 5).
Internal carotid aneurysms located in the intracavernous region account for 3-5% of all intracranial aneurysms [1]. Systemic hypertension is a primary risk factor for development of aneurysm. Life-threatening risk or permanent neurological complications of most carotid cavernous aneurysms (CAA) are relatively low [2]. Despite this, ophthalmic morbidity is a leading consideration for treatment [3]. Diplopia (65% of cases), retro-orbital pain, and unilateral headache are the most common symptoms at presentation of CAA, followed by CN III and CN VI paresis [4]. The mainstay of symptomatic CAA has moved away from surgical and endovascular balloon techniques in favor of endovascular stenting and coiling approaches [4].