Pcom Aneurysm - Dr Sha Pamangadan

interesting clinical case of pcom aneurysm

1. Interesting Case Presentation Dr Shaz Pamangadan

2. 42 / F Housewife Calicut Presented to the EMD c /o right-sided headache - 2 weeks duration.

3. Right sided , Insidious onset , squeezing type of persisting , non -radiating head ache for the last 2 weeks . In addition, she also noted right-sided facial pain and paresthesia . The facial pain was reproducible and originated behind her right ear, with radiation across the face . she also complained of a foreign body sensation in her right eye.

4. No h/o worsening pain with valsalva maneuvres , trauma , fever , neck stiffness , photophobia , nausea , vomiting , altered consciousness , seizures . The patient denied any facial droop or weakness. She also denied any changes in visual acuity.

5. Past history History of migraine attacks , gets aborted with drugs . She noted that the present headache did not have the character of her previous episodes . No other past h/o significant medical or surgical illness .

6. Family history No f/h/o similar illness . No significant neurological illness in family

7. Personal history Mixed diet Sleep decreased Normal bowel / bladder No addictions .

8. On Examination BP - 144/79 mm Hg PR – 82 / mt RR- 17/ mt T- 98.7 F SPO 2 - 100% (room air). No PICCLE Skin , hair , nails , thyroid - Normal

9. CNS HMF – N CN – N MOTOR SYSTEM – N SENSORY –N CEREBELLAR – N SKULL & SPINE – N

10. Other systems CVS- N RS- N GIT – N

11. She was treated with metoclopramide and ketorolac for her migraine while in the emd , with some relief of symptoms. Because her symptoms also appeared consistent with trigeminal neuralgia, she was discharged with a trial of carbamazepine.

12. Then ??? The patient returned to the opd four days later with a chief complaint of right eye pain and pressure with associated blurring of vision.

13. The patient’s sister also noted that the patient’s eyelid appeared droopy. The patient also complained of some numbness to her right side of face.

14. N eurological exam  remarkable for new onset mild to moderate ptosis of the right eyelid and mydriasis of the right pupil . No external ophthalmoplegia . The rest of the physical exam was unremarkable .

15. Based on these new physical ndings , an emergency CT with CTA of the head and neck was performed. The imaging revealed 7mm by 4mm bilobed posterior directed PCOM saccular aneurysm .

16. What happened ? In the operating room a right craniotomy was performed followed by clipping of the right posterior communicating artery. The patient progressed remarkably well after her surgical procedure. She had immediate relief of her facial pain and significant improvement of her CN III palsy and was discharged home three days post-operation.

17. At her outpatient follow-up appointment two weeks post-operation she reported complete resolution of her headaches and had completely normal extra-ocular movements and only mild ptosis on examination.

18. DIAGOSIS : PCOM ANEURYSM WITH ATYPICAL TRIGEMINAL NEURALGIA .

19. Thank you