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2020 Jul 14

World Neurosurg

A very rapidly growing, spontaneous, internal carotid artery dissecting aneurysm triggering simultaneous complete ophthalmoplegia and a cerebral infarct.


Simultaneous ipsilateral complete ophthalmoplegia and multiple cerebral infarctions are very rare, especially secondary to a very rapidly growing, spontaneous dissecting aneurysm in the cavernous segment of the internal carotid artery (ICA). We describe a 26-year-old woman who presented with sudden-onset, right-sided, spontaneous ophthalmoplegia with left hemiparesis. Magnetic resonance imaging revealed a middle cerebral artery territory infarction. Digital subtraction angiography (DSA) revealed multiple arterial dissections involving both the vertebral artery and right ICA, with a dissecting aneurysm in the cavernous segment of the ICA. On day 3, the partial ophthalmoplegia worsened to complete ophthalmoplegia (third, fourth, and sixth cranial nerve palsies), despite conservative treatment. Follow-up DSA showed increased aneurysm size. The dissecting aneurysm was successfully managed by stent-assisted coil embolization. After endovascular treatment, the ophthalmoplegia, ptosis, and headache gradually resolved. This is the first reported case of simultaneous cerebral infarction and complete ophthalmoplegia attributed to a rapidly growing dissecting aneurysm of the cavernous ICA; such aneurysms readily cause thromboembolism. Physicians who treat patients with dissecting aneurysms should carefully monitor aneurysm growth and thromboembolic complications. Close observation and short-term angiographic follow-up should also be considered.