Presentation
Acute onset of severe pain in her right eye, blurring of vision accompanied by a progressive headache.
Patient Data
A non-contrast CT head scan performed on an emergency basis in another hospital revealed no SAH. However, there is a mass centered on the right cavernous sinus, warranting further evaluation with an MRI with contrast.
Axial T1W, T2W, and coronal T2 fat sat images reveal a well-circumscribed giant rounded-shaped mass with heterogenous signal located in the right cavernous sinus, it appears to be in continuity with the cavernous segment of the right internal carotid artery consistent with aneurysm. It exhibits a laminated thrombus characterized by a high signal on T1W and T2WI, representing the thrombosed portion, and rapidly flowing blood as flow voids, representing the patent portion. This configuration gives rise to the characteristic "onion skin appearance". In GRE, it shows blooming (blood).
Post-contrast T1 fat sat images in axial, sagittal, and coronal planes highlight and confirm the presence of a partially thrombosed aneurysm.
The aneurysm causes a slight elevation of the right aspect of the optic chiasm and compression of the right aspect of the pituitary gland. As a consequence, there is a slight deviation of the infundibulum.
There is no associated SAH or IVH.
Case Discussion
A giant aneurysm of the ICA can indeed lead to cavernous sinus syndrome due to compression of cranial nerves III, IV, V and VI. These syndromes typically present with symptoms of ophthalmoplegia and headache. It is life life-threatening disorder that requires immediate evaluation.
Successful flow-diverting stent embolization treated the giant right cavernous ICA aneurysm. The patient is recovering well.
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