Expanded Endoscopic Endonasal Clipping of a Giant Cavernous Carotid Aneurysm

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Cavernous carotid aneurysms are typically small, asymptomatic, and often do not require treatment. We present the case of a 59-year-old woman, a 3-pack-a-day smoker, who presented with the primary complaint of left retro-orbital pain, left complete ophthalmoplegia, left-sided blindness, and right abducens palsy. Imaging revealed a giant right cavernous carotid aneurysm, which had expanded to the contralateral cavernous sinus wall and superiorly through the diaphragm sellae. The patient had previously undergone a balloon test occlusion, which was not passed on clinical grounds and resulted in decreased perfusion and symptoms of ipsilateral cavernous sinus syndrome and was nonadherent to dual antiplatelet therapy. Additionally, the aneurysm had rapidly enlarged over a 3-month period; due to these considerations, an endonasal approach with clipping and reconstruction was chosen. Patient consent was obtained, and the patient underwent an expanded endoscopic endonasal approach for clipping of a giant cavernous carotid aneurysm with reconstruction of the internal carotid artery. Postoperative computerized tomography angiography confirmed placement of the clips and patency of the vessel. At short-term follow-up, the patient's trigeminal pain had successfully resolved and she had retained vision in the right eye. This case demonstrates the feasibility of expanded endonasal approaches in managing this challenging pathology (Video 1).