Ardanu, Muhammad Arief and Ardhi, Mohammad Saiful and Sani, Achmad Firdaus (2026) Total ophthalmoplegia as a rare presentation of cavernous internal carotid artery aneurysm with discordant CTA and DSA findings: a case report. Romanian Journal of Neurology/ Revista Romana de Neurologie, 25 (1). 133 - 137.

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Abstract

Background. Total ophthalmoplegia is a rare but serious presentation of intracranial aneurysm, particularly when lesions arise within the cavernous segment of the internal carotid artery (ICA). Accurate vascular imaging is essential for diagnosis and therapeutic planning. The purpose of this report is to highlight a rare clinical manifestation of a cavernous ICA aneurysm and emphasize a significant diagnostic pitfall caused by a marked discrepancy between computed tomography angiography (CTA) and digital subtraction angiography (DSA) findings. Case report. A 42-year-old man presented with sudden severe headache, left ptosis, diplopia, and complete left ophthalmoplegia. Initial 128-slice CTA revealed a small fusiform aneurysm of the left cavernous ICA measuring approximately 9 � 6 mm without subarachnoid hemorrhage. Endovascular coiling was initially planned. However, DSA performed one week later demonstrated a substantially larger dissecting aneurysm appearing as a focal saccular-like outpouching with a neck of 18.9 mm and a dome measuring 14.8 � 11.22 mm. Based on these findings, the treatment strategy was changed to parent vessel sacrifice. Conclusion. Cavernous ICA aneurysm may present with complete ophthalmoplegia. In anatomically complex regions, CTA can underestimate aneurysm morphology. Confirmatory DSA remains crucial for accurate assessment and appropriate management. © 2026, Amaltea Medical Publishing House. All rights reserved.

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