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A 28 year old woman presented with a history of worsening migraine headaches for 15 years. She reported to have right temporal headaches several times a month accompanied by nausea and photophobia. The patient was treated with flunarizine and rizatriptan 10 mg daily with little response.
MRI of the brain showed findings suggestive of a vascular lesion adjacent to the right cavernous sinus. Digital subtraction angiography (DSA) revealed three aneurysms in the petrous and cavernous segments of the right internal carotid artery unusually situated like “pearls on a string” (fig 1). The most distally located aneurysm arose from the C5 portion, measured 18 mm in diameter and caused a mass effect within the posterior cavernous sinus region. Three-dimensional images obtained after angiography clearly revealed a complex anatomy consisting of rather fusiform dilatations without clear distinction between the neck of the aneurysms and the parent artery (fig 2). Permanent carotid occlusion was performed successfully and she recovered from her migraine episodes with only occasional minor headaches remaining.
Triple carotid aneurysms as described here are extremely uncommon and represent a therapeutic challenge, particularly if located at the skull base. The association of a carotid aneurysm and migraine like headaches in older patients has been described in only a few case reports.1,2 Patients with longstanding headaches or migraine should undergo a brain imaging to exclude an underlying vascular cause which may allow curative treatment. High quality 3D imaging of vascular structures significantly improves understanding of complex vascular anatomy and may facilitate clinical decision making.