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- 98.70 F
• SPO2- 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. • Neurological 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 .

25. Thank you