Cavernous sinus syndrome

A 92-year-old Caucasian female presented with a one-day history of right-sided facial numbness, headache, and binocular, horizontal, and vertical (oblique) diplopia. Past medical history was notable for uterine cancer 30 years prior (treated surgically and in remission), stable, longstanding migraine headaches, and cardiac disease requiring pacemaker placement. External examination revealed right-sided numbness in the V₁ and V₂ distribution, but no facial asymmetry and good orbicularis oculi function bilaterally. Visual acuity was 20/30 in the right eye (OD) and 20/25 in the left eye (OS). Pupils measured 1.5 mm in the dark and 1 mm in the light in both eyes (OU) with no relative afferent pupillary defect. Visual fields were full to confrontation OU. Ocular motility examination revealed complete ophthalmoplegia OD, but normal motility OS (see Fig. 14.1). Corneal sensation was also decreased OD. Slit lamp examination was normal OU. Intraocular pressure measurements and dilated fundus examinations were normal OU. Magnetic resonance imaging (MRI) was unable to be performed due to the patient’s pacemaker. Computed tomography (CT) and computed tomography angiography (CTA) showed bilateral cavernous sinus aneurysms and partially thrombosed and calcified distal internal carotid arterial aneurysms in the cavernous segments measuring 2.8 cm on the right and 2.5 cm on the left (see Fig. 14.2).