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A 59-year-old woman noticed gradual onset of double vision on left lateral gaze in 2006. Over the following year, symptoms of a drooping right eyelid, double vision on right lateral gaze and altered sensation around the right eye emerged, together with pain behind the right eye. The only other significant background was a 40 pack year smoking history. Examination revealed bilateral VI nerve palsies, excoriation over the right forehead reflecting diminished trigeminal ophthalmic nerve sensation and partial right ptosis with impaired pupillary light response (figure 1A). CT of the brain revealed large bilateral carotid aneurysms (figure 1B,C). Further investigation with CT and catheter angiography confirmed the presence of bilateral giant cavernous internal carotid artery (ICA) aneurysms and a smaller right posterior communicating artery aneurysm (figure …
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