AN 89-YEAR-OLD woman with a history of hypertension and Paget disease had a severe throbbing right-sided headache. Two years previously, a fall had resulted in the fracture of her arm, and weeks later, she began to develop pain and swelling in the right eye, followed by numbness of the right forehead and "blurred vision." On a recent neurologic examination (Figure 1A), she had marked right ptosis, right esotropia, and complete ophthalmoplegia. The right pupil was fixed and dilated (Figure 1B). Sensation was diminished in all modalities in the right ophthalmic (V1) and maxillary (V2) divisions of the trigeminal nerve. Computed tomography of the head (Figure 2) revealed lesions that were larger on the right than on the left side in the cavernous sinuses. Axial T1-weighted magnetic resonance imaging (Figure 3A) and magnetic resonance angiography (Figure 3B and C) demonstrated bilateral cavernous carotid aneurysms containing thrombi, presumably causing compression and dysfunction of cranial nerves III, IV, V1, V2, and VI in the right cavernous sinus. Attempts at endovascular occlusion of the aneurysm on the right side were unsuccessful, and surgery was declined. Her throbbing headaches were localized to the right temple and upper face and were presumably caused by the pulsating aneurysm and impingement on the trigeminal nerves. Her headache resolved following treatment with gabapentin.
Atri A, Sheen V. Cavernous Sinus Syndrome and Headache Due to Bilateral Carotid Artery Aneurysms. Arch Neurol. 2003;60(9):1327-1328. doi:10.1001/archneur.60.9.1327