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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 234-236

Elderly female presenting with "lazy" giant intracranial aneurysm


1 Department of Ophthalmology, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
2 Department of Pediatrics, Gian Sagar Medical College and Hospital, Patiala, Punjab, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Rajwinder Kaur
Department of Ophthalmology, Gian Sagar Medical College and Hospital, Village Ram Nagar, Tehsil Rajpura, Patiala - 140 601, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_83_17

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  Abstract 


Multiple aneurysms of anterior intracranial circulation including a giant one are rare; progressing slowly, these “little pulsatile bumps” often present with ocular and neurological symptoms. This case reports a 70-year-old hypertensive female with multiple small and a single giant intracranial aneurysm, diagnosed on basis of ophthalmological manifestations 3 years back, and the patient still survives with these unruptured vascular deformations.

Keywords: Aneurysm, intracranial, nerve palsies, subarachnoid hemorrhage


How to cite this article:
Kaur R, Kaur M, Singh H. Elderly female presenting with "lazy" giant intracranial aneurysm. Kerala J Ophthalmol 2017;29:234-6

How to cite this URL:
Kaur R, Kaur M, Singh H. Elderly female presenting with "lazy" giant intracranial aneurysm. Kerala J Ophthalmol [serial online] 2017 [cited 2018 Sep 19];29:234-6. Available from: http://www.kjophthal.com/text.asp?2017/29/3/234/224299




  Introduction Top


Multiple nerve palsies may root back to many medical and surgical causes among which aneurysms of internal carotid artery (ICA) are overshadowed, giant one are rare and have higher incidence for rupture which leads to subarachnoid hemorrhage that accounts for most serious complication of these vascular pathologies. Depending on size, these aneurysms may be classified as small <10 mm, medium 10–25 mm, and large >25 mm in sizes.[1] Anatomical distribution determines the symptomology ranging from focal seizures to ocular involvement [2],[3] to neurological to ruptured one. Patients with multiple intracranial aneurysms may be particularly susceptible to new aneurysm formation.[4]


  Case Report Top


A 70-year-old female presented with decreased visual acuity of the left eye for the last 4–5 years, which was gradual in onset, progressive in nature associated double vision with no history of pain in eyes, headache, limb weakness, sensory deprivation, facial asymmetry, nasal regurgitation, slurring of speech, bladder bowel dysfunction, and gait abnormalities. The patient had a history of hypertension × 30 years on regular oral treatment. On examination, the patient was conscious, alert, oriented on general examination. Best-corrected visual acuity of the right eye was 20/40 and left eye was PL + with intraocular pressure of both eyes within normal range. In neutral position, right eye is in normal and in left eye, ptosis is present [Figure 1]. Extraocular movements in right eye are normal and in left eye, all extraocular muscles show restricted movements [Figure 2].
Figure 1: In neutral position, right eye is in normal, and in left eye, ptosis is present

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Figure 2: Extraocular movements in right eye are normal and in left eye, all extraocular muscles show restricted movements

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Pupillary reaction was normal in right eye with pupil measuring 3 mm in size, and in left eye, relative afferent pupillary defect was present with pupil measuring 5 mm in size [Figure 3]. Right eye corneal reflex is normal and absent in left eye. On slit lamp, anterior segment is normal, pseudophakia present in both eyes. On dilated fundoscopy, [Figure 4]. Central nervous system examination reveals 3rd, 4th, 5th, and 6th cranial nerve paralysis on the left side with no other motor, sensory, or higher function deficit.
Figure 3: Pupillary reaction was normal in right eye with pupil measuring 3 mm in size, and in left eye, relative afferent pupillary defect was present with pupil measuring 5 mm in size

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Figure 4: Cupping present in right eye, Cup disc ratio: 0.7:1 and in left eye, disc pallor present

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Magnetic resonance imaging (MRI) and consequent digital substraction angiography revealed the right cavernous ICA aneurysm measuring 1.2 mm in size (neck 3.5 mm), ophthalmic segment of right ICA aneurysm arising superiorly 4.3 mm × 3.4 mm (neck 4.4 mm) and arising inferiorly 3 mm × 2.4 mm (neck 3.1 mm), left cavernous ICA aneurysm 2.7 mm × 2.5 mm × 2.2 cm in sizes depicting gross compression of left anterior cerebral artery and middle cerebral artery filling good from right ICA [Figure 5], [Figure 6], [Figure 7].
Figure 5: Magnetic resonance imaging revealed right cavernous internal carotid artery aneurysm 1.2 mm (neck 3.5 mm), ophthalmic segment of right internal carotid artery aneurysm arising superiorly 4.3 mm × 3.4 mm (neck 4.4 mm) and arising inferiorly 3 mm × 2.4 mm (neck 3.1 mm), left cavernous internal carotid artery aneurysm 2.7 cm × 2.5 cm × 2.2 cm in sizes depicting gross compression of left anterior cerebral artery and middle cerebral artery filling good from right internal carotid artery

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Figure 6: Magnetic resonance angiography revealed right cavernous internal carotid artery aneurysm

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Figure 7: Digital substraction angiography revealed right cavernous internal carotid artery aneurysm

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The patient was referred to neurosurgical unit for further management; surgery was advised but the patient refused the procedure. During the course, the patient initially presented with third nerve palsy and later on the aneurysm enlarged, multiple cranial nerves fourth, fifth, and sixth were also involved, but the patient still survives with these with only ocular involvement sparing other systems.


  Discussion Top


The course of giant internal carotid artery aneurysm is highly unpredictable, may rupture to cause subarachnoid hemorrhage, or may proceed as unruptured vascular bumps causing mass effects. According to the International aneurysms study, giant aneurysms carry 6% annual risk of rupture compared with a 1%–3% annual risk for smaller aneurysms. ICA is the predominant localization of giant intracranial aneurysms associated with a high risk of rupture and poor clinical outcome. The risk of rupture in giant aneurysms is as high as 50% in 5 years.[5] The best estimate of the rupture risk of intracranial aneurysms is arguably from a recent meta-analysis,[6] which yielded an annual rupture risk of 0.6%–1.3%.[6] In our case, atypical course followed by these aneurysm is of interest, a female in her early 70s with single giant intracranial aneurysm of left ICA presenting with multiple cranial nerve palsies and multiple small aneurysms involving right ICA although there was no neural involvement and leading indolent course. The management of unruptured intracranial aneurysms depends on the natural history of these lesions and on morbidity and mortality rates associated with repair. On the basis of the rupture rates and treatment risks in our study, it appears unlikely that surgery will reduce the rates of disability and death in patients with unruptured intracranial aneurysms smaller than 10 mm in diameter and no history of subarachnoid hemorrhage.[7] In some of the studies, surgical management of intracranial aneurysms has shown complete resolution of the presenting symptoms.[8]


  Conclusion Top


In such cases involving aneurysms of intracranial part of ICA, prompt diagnosis on basis of history, risk factors, complete ocular and systemic examination, and MRI angiography of cerebral vessels helps diagnose this life-threatening pathology. Some aneurysm may rupture leading to dreadful complication of subarachnoid hemorrhage or may stay silent. However, surgical management has shown complete resolution of presenting symptoms in some studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Choi IS, David C. Giant intracranial aneurysms: Development, clinical presentation and treatment. Eur J Radiol 2003;46:178-94.  Back to cited text no. 1
    
2.
Terzidou C, Dlianis G, Zacharaki F. Ocular simptomatology, management and clinical outcome of giant intracranial aneurysm. Case Rep Med 2012;2012:643965.  Back to cited text no. 2
    
3.
Peiris JB, Ross Russell RW. Giant aneurysms of the carotid system presenting as visual field defect. J Neurol Neurosurg Psychiatry 1980;43:1053-64.  Back to cited text no. 3
    
4.
David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 1999;91:396-401.  Back to cited text no. 4
    
5.
Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr., Piepgras DG, et al. Unruptured intracranial aneurysms: Natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362:103-10.  Back to cited text no. 5
    
6.
Wermer MJ, van der Schaaf IC, Algra A, Rinkel GJ. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: An updated meta-analysis. Stroke 2007;38:1404-10.  Back to cited text no. 6
    
7.
International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms – Risk of rupture and risks of surgical intervention. N Engl J Med 1998;339:1725-33.  Back to cited text no. 7
    
8.
Kaur R, Gill HS, Khan B, Pathak N. Painful isolated third nerve palsy: A life saving diagnosis. Sch J Med Case Rep 2015;3:1012-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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