Cranial neuropathy due to an internal carotid artery aneurysm: Early recovery with a flow diverter stent

Introduction: Intracranial aneurysms can present with cranial neuropathy. Aneurysms of the left distal cavernous (C4)/clinoid (C5) internal carotid artery (ICA) can affect the abducens nerve because of their anatomical location. In unruptured compressive aneurysms, coiling may not always be suitable. This report presents early clinical recovery achieved with a flow diverter (FD) stent in cranial neuropathy caused by a left ICA distal cavernous (C4)/clinoid (C5) aneurysm.Case: A 54-year-old woman presented with double vision that had persisted for 3–4 months. Neurological examination revealed left abducens palsy. Magnetic resonance angiography (MRA) showed a 3.8×7 mm aneurysm in the distal cavernous (C4)/clinoid (C5) segment of the left ICA; the diagnosis was confirmed by digital subtraction angiography (DSA), which reported a saccular aneurysm with a 5×5.5 mm dome and a 4.5 mm neck. Because the aneurysm was in a compressive position, coiling was not planned; dual antiplatelet therapy was started and FD stent placement was planned. Under general anesthesia, a 4.5×17 mm Surpass FD stent was successfully deployed via the right femoral artery. The procedure was completed without complications. At 12 hours after the procedure, marked regression of the cranial neuropathy findings was observed. The patient was discharged on acetylsalicylic acid and ticagrelor. At the 3-month and 6-month follow-ups, there were no active neurological complaints; the modified Rankin Scale (mRS) score was 0 at both visits. At the 6-month visit, ticagrelor was discontinued and treatment was switched to a combination of acetylsalicylic acid and clopidogrel (Figure 1–3).Discussion/Conclusion: In unruptured ICA aneurysms presenting with cranial neuropathy, FD stenting is a safe and effective treatment option. The most striking finding in this case was the rapid clinical improvement observed 12 hours after FD stenting. Recovery is generally reported to occur over weeks to months in the literature, so such an early response is rarely seen. The case draws attention to the early neuroprotective potential of FD stenting in compressive aneurysms.Keywords: