Bilateral Meckel's Cave Cephalocele Presenting as Cranial Nerve VI Palsy: A Case Report

Meckel's cave cephalocele, also known as petrous apex cephalocele (PAC), is a rare cystic lesion caused by herniation of the cerebrospinal fluid into the Meckel's cave. Bilateral PACs are exceptionally rare, with only 21 reported cases. PACs may present with headache, diplopia, tinnitus, or cranial nerve palsy.

A 74-year-old male presented with acute onset headache, vision changes, and gait instability. His medical history included hypertension and melanoma. Examination revealed a left cranial nerve VI palsy. Initial imaging with head CT and CTA showed no acute intracranial abnormalities but revealed moderate chronic sinusitis. Magnetic resonance imaging demonstrated large bilateral Meckel's cave cephaloceles, more prominent on the left, with mass effect on the inferior margins of the cavernous sinus. Steroid treatment was initiated for suspected influenza-associated cranial neuropathy. Follow-up did not reveal an immediate improvement. However, after several weeks of steroid treatment, his symptoms improved significantly. The patient deferred surgical intervention.

This case highlights a rare presentation of bilateral PACs with cranial nerve VI palsy. Although surgical intervention may be definitive, conservative treatment can provide relief of symptoms in select cases. More research is needed to guide optimal management strategies.