Case of the Month

January 2011 by Aclan Dogan, M.D.

Right Cavernous ICA Giant Aneurysm


Patient history and diagnosis

A 54 year-old female was admitted with: 3 weeks of severe headache, progressive double vision and severe retro orbital pain. Past medical history included: shingles and osteonecrosis. Past surgical history included: an appendectomy, and a hip replacement.

Brain magnetic resonance imaging revealed:

− 2.1 x 2.2 cm saccular right cavernous internal carotid artery (ICA) aneurysm2D and 3D cerebral angiogram images show a right giant cavernous ICA

− mass effect on the adjacent cavernous sinus, Meckel’s cave, and right temporal lobe

Neurological Examination Results:

  • Mental status: Normal consciousness, orientation, affect and fluency
  • Cranial Nerves: 2nd-12th intact on detailed examination
  • Motor: Normal strength, muscle bulk, and tone
  • Sensory: Intact to pinprick and light touch
  • Cerebellar: Normal finger-to-nose and rapid alternating movements
  • Gait: Normal, Tandem and Romberg negative
  • Deep Tendon Reflexes: Present and normoactive
  • Pathologic Reflexes: Absent

Plan and Surgical Treatment

Indications for cavernous ICA aneurysms are:

− Debilitating pain

− Vision loss

− Diplopia

− Sphenoid sinus erosion

Treatment of giant cavernous aneurysms includes:

− ICA occlusion after balloon test occlusion

− Occlusion of the aneurysm with a covered stent

− Coil embolization of the aneurysm with/without stent

− Occlusion of the ICA with extracranial to intracranial (EC/IC) bypass

The patient tolerated the balloon test occlusion, however since there is 5-22% delayed ischemic complication and 5% mortality risk after a successful balloon test occlusion, an ICA occlusion with EC/IC bypass was selected.

The patient was taken to the operating room and a radial artery graft was harvested and right external carotid artery to middle cerebral artery by-pass surgery using the radial artery graft was performed without complication. Immediately after surgery the patient was taken to the angio-suite and the right ICA and aneurysm occluded with coils.



The patient tolerated the procedures well without complication and was discharged home on postoperative day three.

Download .pdf files that include pre- and postoperative imaging.