Bilateral cavernous segments internal carotid artery aneurysms
Presentation
Acute onset of severe headache and blurred vision with background history of hypertension.
Patient Data
Abnormal high attenuating content within the right cavernous sinus as well as convexities in lateral walls of both cavernous sinuses. The sella turcica is widened and expanded.
Optic chiasm is compressed.
From the non-contrast CT brain study, the identification of sella turcica/cavernous sinuses mass with possible hemorrhagic content raise suspicion of possible two differential diagnoses, either hemorrhagic pituitary macroadenoma with lateral cavernous sinuses extension or internal carotid arteries (ICA) aneurysm.
Proceeded with MRI brain/pituitary gland.
A well circumscribed spherical shaped mass with abnormal internal and peripheral flow voids occupying the left cavernous sinus. It appears to be in continuity with the cavernous segment of left internal carotid artery as saccular aneurysm. This mass enhances avidly as artery in post contrast study.
Annotated images showing the specific imaging findings in non-contrast CT brain, MRI brain: T1W, T2W, T1 post contrast and MR angiogram.
Case Discussion
Bilateral cavernous segments internal carotid arteries aneurysms are very rare occurence, where MR imaging features suggest the right sided aneurysm to be either thrombosed or ruptured with sealed intercavernous subacute hematoma as well as patent left cavernous ICA aneurysm. The mass effect of the right sided thrombosed aneurysm or intercavernous hematoma has resulted in right cranial nerve III, IV, V1, V2 and VI palsies and optic chiasm compression.
Thrombosed right internal carotid artery (C2 till C6 segment) where the right C7 segment is solely supplied by left ACA via the patent anterior communicating artery. No MR evidence of acute brain infarction.
This case shows the importance of considering aneurysm as differential diagnosis for sella turcica lesion, as internal carotid arteries pass through the cavernous sinuses.
T1-weighted, T2-weighted and post contrast MRI sequences are important sequences to look for any flow voids as black signal intensity. There are only three things black on MRI : air, bone and rapid blood flow.
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