Successful treatment with flow diverter for small carotid cavernous aneurysm with oculomotor palsy: A case re port

The effectiveness of flow diverters (FDs) in treating small aneurysms that cause neurological symptoms remains unclear. We present a case of a small carotid cavernous aneurysm (CCA) with oculomotor palsy treated early with an FD, resulting in favorable outcomes. A 74-year-old woman presented with a rapidly progressing left pupil-sparing oculomotor palsy. Magnetic resonance imaging and computed tomography angiography demonstrated a 4-mm CCA arising from the lateral wall of the left internal carotid artery (ICA). Further, investigation suggested that the oculomotor palsy could be caused by the small CCA or benign Tolosa–Hunt syndrome. On the 4th day of admission, we initiated steroid therapy simultaneously with antiplatelet therapy for diagnosis and treatment; however, the symptoms did not improve. Consequently, on the 12th day of admission, we performed an endovascular procedure for the small CCA using an FD, expecting decreased aneurysm’s pulsation and mass effect on the oculomotor nerve. Dual antiplatelet therapy and steroid therapy were initiated simultaneously 7 days before endovascular treatment. A pipeline embolization device was deployed between the left C7 segment of the ICA, just proximal to the left anterior choroidal artery, and the C3 segment. Post-procedure digital subtraction angiography (DSA) revealed no changes in aneurysm findings. Oculomotor palsy substantially improved immediately after the procedure. The patient had an uneventful course after the procedure, and follow-up DSA after 6 months revealed complete obliteration of the aneurysm. We successfully treated a case of small CCA with oculomotor palsy using early intervention with an FD, suggesting the effectiveness of this approach in addressing small CCAs causing neurological symptoms. However, further studies are required to confirm the optimal nature of FDs.