Unusual presentations of cavernous carotid aneurysms

OBJECTIVES: To report atypical features of cavernous carotid aneurysms (CCAs) that can create complex management problems if not recognized. MATERIALS AND METHODS: Retrospective analysis was performed on 202 CCAs in 183 patients, referred to a tertiary neuro-ophthalmology/neurovascular service. RESULTS: Six cases of CCA with unusual characteristics were identified. Two patients, one with thrombocytosis and the other with disseminated intravascular coagulation, developed cerebral infarcts presumably due to embolism from the CCA. One patient presented with a carotid cavernous fistula (CCF) not initially recognized due to the lack of typical clinical and radiological findings. One patient presented with acute ischemic necrosis of the globe due to ruptured CCA causing a CCF. One patient, with magnetic resonance images and cerebral angiography demonstration of intradural extension of the CCA, presented with a partial third nerve paresis and experienced a subarachnoid hemorrhage more than two years later. One patient presented with medically refractory headaches at the age of nine years. Five patients were treated by endovascular and one by surgical closure of the internal carotid artery with or without endosaccular aneurysmal occlusion. Except for the child who presented with headaches, all patients improved clinically after treatment. CONCLUSIONS: Patients with CCA may not have the expected painful ophthalmoplegia presentation or MRI features. Careful clinical evaluation and magnetic resonance angiography should allow treatment planning prior to cerebral angiography.