This document presents the case of a 42-year-old woman who presented with a two-week history of right-sided headaches and facial pain. Her symptoms did not initially improve with migraine treatment. She later returned with new symptoms of right eye pain, pressure, and blurry vision as well as right eyelid droopiness. Examination revealed ptosis and mydriasis of the right eye. A CT scan identified a 7mm bilobed posterior PCOM aneurysm. She underwent a craniotomy and clipping of the aneurysm, which provided immediate relief of her symptoms. At follow-up, her headaches, cranial nerve palsies, and vision had fully resolved, with the diagnosis being a PCOM aneurys

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