Giant unruptured intracranial aneurysm manifesting as ischemic stroke

 A 75-year-old hypertensive woman presented with 2-day history of right sided weakness and speech disturbances. Neurologic examination revealed right hemiparesis, anosmia and dysfunction of the left third and sixth cranial nerves. Brain computed tomography scan (A,B) followed by magnetic resonance angiography (C,D) discovered an unruptured cavernous carotid aneurysm measuring 40 × 39 mm in diameter (stars) on the left side with a concomitant acute ipsilateral frontal infarction (arrows). The giant calcified saccular aneurysm contained a dense, structured, and intraluminal thrombus. Laboratory studies were within normal range. Based on these findings, the patient was diagnosed with a thrombosed unruptured carotid-cavernous aneurysm with homolateral anterior cerebral artery ischemic stroke. Exploration of the supra-aortic arteries was normal. No other sources of brain infarction were found on electrocardiogram, transthoracic echocardiography and Holter monitoring. The patient was referred to interventional neuroradiology for endovascular coiling of the aneurysm.