March 2018

A 55-year-old Woman with Progressive Diplopia

A 55-year-old female patient was referred to the outpatient clinic with double vision x3-4 weeks. Her vision gets worse when she looks on right side and improves with closure of her right eye. She denied any other symptoms.

Awake, alert and oriented to time, place, person
Cranial nerves: Right 6th nerve palsy (right lateral rectus palsy); other CNs are intact
Strength 5/5 throughout
Sensations intact bilaterally to pinprick, light touch and temperature
DTRs – 2+ symmetric

Axial T1

Axial T2

Coronal T1 Gad+

Fig 1

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Fig 6

1. Based on the information available, how would you classify first aneurysm with respect to its size?
2. What endovascular method is the most preferred for the treatment of this patient’s complex right cavernous aneurysm?
3. What are the long term (~5 year) complete occlusion rates after the treatment of complex cavernous aneurysm using preferred endovascular method?
4. Which of the following describes you?
5. I practice in one of the following locations.
7. This patient also found to have incidental left internal carotid artery bifurcation aneurysm. The aneurysm projects anteriorly. Based on morphology being the sole criteria what is the best way to treat this aneurysm?

Your answers will be added to those already obtained and tabulated at the end of the month.


  • Ishibashi T, Murayama Y, Urashima M, Saguchi T, Ebara M, Arakawa H, Irie K, Takao H, Abe T. Unruptured intracranial aneurysms: incidence of rupture and risk factors. Stroke. 2009 Jan;40(1):313-6. 
  • Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosfoi M, Cekirge SH, Nelson PK. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013 Jun;267(3):858-68.
  • Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, Levy EI, McDougall CG, Szikora I, Lanzino G, Woo HH, Lopes DK, Siddiqui AH, Albuquerque FC, Fiorella DJ, Saatci I, Cekirge SH, Berez AL, Cher DJ, Berentei Z, Marosfoi M, Nelson PK. Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial. Neurosurgery. 2017 Jan 1;80(1):40-48.

Recommended Products:

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Guidelines for the Management of Patients with Unruptured Intracranial Aneurysms