Cavernous sinus syndrome due to cavernous internal carotid artery dissection: A case report

Abstract

Rationale: Cavernous internal carotid artery dissection (ICAD) is a rare cause of cavernous sinus syndrome, presenting diagnostic challenges, particularly in resource-limited settings.

Patient’s concern: A 43-year-old man presented with sudden, painless left eye blindness, partial ptosis and reduced facial sensation. Examination revealed a relative afferent pupillary defect, anisocoria, mild ophthalmoplegia and a pale optic disc. Initial computed tomography imaging was unremarkable, and lumbar puncture suggested meningoencephalitis. Despite treatment, his condition deteriorated to complete ptosis and total ophthalmoplegia. Urgent magnetic resonance imaging and computed tomography angiography confirmed cavernous internal carotid artery dissection and multiple areas of infarction.

Diagnosis: Cavernous sinus syndrome secondary to cavernous ICAD with non-arteritic ischemic optic neuropathy, total ophthalmoplegia and trigeminal nerve palsy.

Interventions: The patient initially received treatment for meningoencephalitis. Upon confirming the diagnosis of ICAD, he declined surgical intervention.

Outcomes: Irreversible left eye blindness.

Lessons: This case highlights the progressive nature of cavernous ICAD, the critical role of advanced imaging in diagnosis, and the need for clinical vigilance in resource-limited settings for timely diagnosis and intervention.

Keywords

Internal carotid artery dissection / Non-arteritic ischemic optic neuropathy / Ophthalmoplegia / Trigeminal nerve palsy

Conflict of interest statement

The authors have no conflicts of interest.

Funding

This study received no extramural funding.

Acknowledgement

We extend our gratitude to the Director General of Health Malaysia for granting permission to publish this article.

Publisher’s note

The Publisher of the Journal remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

[1] Goodfriend SD, Tadi P, Koury R. Carotid artery dissection 2022. In: StatPearls. Treasure Island (FL): StatPearls Publishing. [Online] Available from:

[2] Chaves C, Estol C, Esnaola MM, Gorson K, O’Donoghue M, de Witt LD, et al. Arterial dissection is now recognized as a common cause of ischemic stroke in young and middle-aged adults. Arch Neurol 2002; 59(6): 977-981.

[3] Pessin MS, Adelman LA, Barbas NR. Spontaneous intracranial carotid artery dissection. Stroke 1989; 20(8): 1100-1103.

[4] Levy D, Sharma S, Grigorova Y, Farci F, Le JL. Aortic Dissection 2024. In: StatPearlsInternet.Treasure Island (FL): StatPearls Publishing. [Online] Available from:

[5] Bakan AA, Alkan A, Kurtcan S, Aralaşmak A, Tokdemir S, Mehdi E, et al. Cavernous sinus: A comprehensive review of its anatomy, pathologic conditions, and imaging features. Clin Neuroradiol 2014; 25(2): 109-125.

[6] Salvetat ML, Pellegrini F, Spadea L, Salati C, Zeppieri M. Non-arteritic anterior ischemic optic neuropathy (NA-AION): A comprehensive overview. Vision (Basel) 2023; 7(4): 72.

[7] Siddiqui A, Kim N, Kogan M, Natarajan S, Sawyer R, Snyder K. Third nerve palsy following carotid artery dissection and posterior cerebral artery thrombectomy: Case report and review of the literature. Surg Neurol Int 2014; 5(14): 497-500.

[8] Hakimi R, Sivakumar S. Imaging of carotid dissection. Curr Pain and Headache Rep 2019; 23(1): 2.

[9] Gardner DJ, Gosink BB, Kallman CE. Internal carotid artery dissections: Duplex ultrasound imaging. J Ultrasound Med 1991; 10(11): 607-614.