Barzilai University Medical Center

119 Research Day 2020 Barzilai University Medical Center 85 "4 DOWN"- LIFE THREATENING DILEMMAS IN AN ISOLATED FOURTH NERVE PALSY DUE TO A CAVERNOUS CAROTID ANEURYSM Dua Masarwa, Azaria Simonovich, Shahab Davidpour, Muhammad Biadsy, Eyal Aloni Department of Ophthalmology, Barzilai University Medical Center, Ashkelon, Israel Background The natural history and the clinical presentation of Cavernous Carotid Aneurysms (CCA) are largely different from other intracranial aneurysms and have a much lower risk of aneurysm rupture, especially in asymptomatic patients, who are usually observed. Controversy exists regarding the management of unruptured symptomatic CCA, which predispose patients to increased risk of rupture. We will present a rare presentation of a patient with an isolated right fourth nerve palsy due to a CCA and expand on the life-threatening treatment dilemmas. Methods Descriptive case report. Results A thirty-nine years old, healthy, 36 weeks pregnant women, complained of unpainful binocular vertical double vision, since the first trimester of pregnancy. She had no prior history of head trauma, childhood strabismus, thyroid disease or myasthenia gravis symptoms. Neuro-Ophthalmic examination showed a right hypertropia with findings suggestive of a right fourth nerve palsy and otherwise a normal neuro-ophthalmological exam. Brain MRI and MRA revealed an unusual laterally directed CCA compressing the right fourth cranial nerve. Following consultations, she underwent an uneventful endovascular aneurysm coiling that improved her right hypertropia significantly with almost complete resolution of her complaints. Conclusion A laterally displeased CCA can cause a rare presentation of isolated fourth nerve palsy. Treatment of the aneurysm ten months following the initial complaint improved the double vision markedly. The decision regarding treatment of symptomatic CCA should take into account the risk of rupture, the risks associated with the procedure and the expected resolution of symptoms.