Peripheral ophthalmic artery aneurysm

Peripheral Ophthalmic Artery Aneurysm Associated with Multifocal Intracranial and Extracranial Aneurysms: Case Report and Literature Review

Peripheral ophthalmic artery aneurysm is a rare disease entity. We review the relevant literature and report a case of fusiform aneurysm involving the entire intraorbital ophthalmic artery in association with multiple intracranial and extracranial aneurysms, diagnosed on digital subtraction angiography. The patient suffered irreversible blindness secondary to compressive optic neuropathy which did not improve after a 3-day trial of intravenous methylprednisolone. Autoimmune screen was normal. The underlying cause is unknown.

Proper ophthalmic artery aneurysms

Background

The ophthalmic segment of the internal carotid artery (ICA) represents a common site for cerebral aneurysms. However, aneurysms of the ophthalmic artery (OphA) itself represent rare lesions and have been associated with trauma and flow-related lesions such as arteriovenous fistulas or malformations. Here, we explore clinical and radiological features of four patients managed for five proper ophthalmic artery aneurysms (POAAs).

Methods

Patients undergoing diagnostic cerebral angiogram (DCA) between January 2018 and November 2021 with newly or previously identified POAA were retrospectively reviewed. Clinical and radiological data were analyzed to identify common and unique features.

Results

Four patients with identification of five POAA were identified. Three patients suffered traumatic brain injury with subsequent identification of POAA on DCA. Patient 1 presented with a traumatic carotid-cavernous-sinus fistula requiring transvenous coil embolization and second stage flow diversion of the ICA. Patient 2 suffered a gunshot wound with ICA compromise, ethmoidal dural arteriovenous fistula (dAVF) development with rapid growth of two POAAs eventually requiring Onyx embolization. Patient 3 was assaulted and DCA showed a POAA without any other cerebrovascular pathology. Patient 4 had undergone N-butyl cyanoacrylate embolization of an ethmoidal dAVF 13 years ago with the feeding OphA carrying a large POAA. Re-DCADCA was performed for a newly developed and unrelated transverse-sigmoid-sinus dAVF.

Conclusion

Management of POAAs poses a challenge to neurovascular surgeons since POAAs inherit a risk for visual deterioration or hemorrhage. DCA facilitates identification of coexisting cerebrovascular pathology. If clinically silent and not accompanied by cerebrovascular disease, observation appears reasonable.

Partial medial clinoidectomy with optic canal roof drilling for clipping of ophthalmic artery aneurysms: how I do it

BACKGROUND

Clipping of ophthalmic artery (OA) aneurysms present one of the treatment strategies for long-term disease management. Existing surgical techniques primarily require extra/intradural removal of the anterior clinoid process, carrying a higher risk of infection, damage to surrounding structures or technical complications.

METHODS

We present the technique of minimally invasive partial medial clinoidectomy with the unroofing of the optic canal for surgical clipping of OA aneurysms, and besides its pros and cons, we also discuss proper technical indications.

CONCLUSION

The partial medial clinoidectomy improves manoeuvrability around the paraclinoid region, provides better protection for adjacent structures and renders excellent treatment outcome.

An Anatomical Feasibility Study for Revascularization of the Ophthalmic Artery. Part II: Intraorbital Segment

INTRODUCTION

Distal ophthalmic artery (OpA) aneurysms are a rare subset of vascular lesions with lack of optimal treatment. The management of these aneurysms may require complete occlusion of the parent vessel, carrying a risk of permanent visual impairment due to individual variations of extracranial collateral flow to the intraorbital ophthalmic artery (iOpA).

OBJECTIVE

To test the feasibility of a superficial temporal artery (STA) to iOpA bypass to prevent acute ischemic retinal injury. Two different transorbital corridors (superomedial and posterolateral approaches) for this bypass were evaluated.

METHODS

Each approach was carried out in 10 specimens each (n = 20). The corridors were compared to achieve the optimal exposure of the iOpA until the central retinal artery origin was visualized. An end-to-end anastomosis was performed from STA-to-iOpA. The arterial caliber and length at the anastomotic sites, required donor artery length, and intraorbital surgical area were measured.

RESULTS

STA-iOpA bypasses were performed in all specimens. For the posterolateral transorbital approach, the mean caliber of STA was 1.8 ± 0.2 mm, and that of iOpA was 1.7 ± 0.5 mm. The required STA graft length was 78.3 ± 1 mm with lateral iOpA transposition of 8.2 ± 1.1 mm. For the superomedial approach, the average STA length required for an intraorbital bypass was 130.8 ± 14.0 mm. The mean calibers of iOpA and STA were 1.5 ± 0.1 mm and 1.5 ± 0.1 mm, respectively.

CONCLUSIONS

This study demonstrates the feasibility of a novel revascularization technique of the iOpA using 2 different transorbital approaches. These techniques can be used in the management of intraorbital lesions such as OpA aneurysms, tumoral infiltrations, or intraoperative injuries.

Spontaneous Regression of a True Intracanalicular Fusiform Ophthalmic Artery Aneurysm After Endovascular Treatment of an Associated Dural Arteriovenous Fistula

BACKGROUND

Ophthalmic trunk aneurysms associated with other vascular malformations are extremely rare, and little is known regarding its natural history and options of treatment.

CASE DESCRIPTION

We present the interesting case of a 51-year-old man who was admitted with progressive visual loss secondary to a concurrent fusiform ophthalmic trunk aneurysm associated with a dural arteriovenous fistula. He was treated with transarterial embolization of the fistulous point.

CONCLUSIONS

A follow-up angiogram at 6 months showed complete obliteration of the dural arteriovenous fistula and regression of the ophthalmic trunk aneurysm. The literature is reviewed, and potential pathophysiologic mechanisms leading to this association and regression in this subgroup of aneurysms are discussed.

Endovascular Management of Multiple Dysplastic Aneurysms in a Young Man with an Unknown Underlying Cause: A Case Report and Review of the Literature

BACKGROUND

Intracranial aneurysms are the leading cause of nontraumatic subarachnoid hemorrhage and are most commonly associated with the anterior cerebral artery (ACA) and anterior communicating artery complex. We describe the presentation and management of a 27-year-old man with concurrent bilateral A1-2 junction aneurysms and fusiform intraorbital ophthalmic artery (OA) aneurysms.

CASE DESCRIPTION

A 27-year-old man with no past medical history presented with 3 months of headaches. Imaging showed a large dysplastic left A1-2 junction aneurysm and a smaller saccular right A1-2 junction aneurysm, with potentially adherent domes. Two fusiform aneurysms of the intraorbital segment of the left OA were also identified. The patient underwent coil-assisted pipeline embolization of the left A1-A2 aneurysm, with complete obliteration and reconstitution of the normal parent vessel. The patient underwent coil embolization of the right A1-2 aneurysm 3 weeks later, which was found to have grown significantly at the time of treatment. Three-month follow-up showed spontaneous resolution of the OA aneurysms, persistent obliteration of the left aneurysm, and significant recurrence of the right aneurysm, which was treated with stent-assisted coil embolization. A second recurrence 3 months later was successfully treated with repeat coiling. At the time of this treatment, the patient was also found to have 2 de novo distal middle cerebral artery and ACA dysplastic aneurysms, which were not treated. Follow-up angiography 6 weeks later showed stable complete obliteration of the right A1-2 aneurysm and interval complete resolution of the dysplastic middle cerebral artery aneurysm. The distal ACA aneurysm was observed to have minimally increased in size; however, the parent vessel showed signs of interval partial thrombosis with contrast stasis within the aneurysm. This final aneurysm is being followed with serial imaging. The patient remains neurologically intact with complete resolution of his headaches.

CONCLUSIONS

We report the case of a young man with no past medical history who presented with multiple dysplastic aneurysms. Successful staged endovascular intervention resulted in obliteration of aneurysms with spontaneous obliteration of the intraorbital OA aneurysms observed at 3 months. We present this case to review the multiple challenges of managing complex ACA aneurysms and to highlight the usefulness of endovascular intervention in their treatment.

Acute neurological visual loss in young adults: causes, diagnosis and management

Visual loss in the young adult can be caused by demyelinating diseases, inflammatory and autoimmune processes, infections, ischaemic events, and compressive lesions of the optic nerve. Diagnosis of the aetiologies of visual loss is reached by combining data from radiological studies, electrophysiological tests, and blood and cerebrospinal fluid analysis. Treatment is primarily aimed at decreasing the insult on the optic nerve and eventually controlling the primary disorder. The literature discusses separately the different aetiologies of visual loss. We present a review of the clinical characteristics of visual loss in the young adult, the different diagnostic measures, and the latest therapeutic strategies. The aim of this work is to summarise this entity in a practical way to guide clinicians in the diagnosis and management of this disorder.

Case Report of Debilitating Headaches and a Coexisting Ophthalmic Artery Aneurysm: An Indication for Treatment?

OBJECTIVE

We present a case of a patient who had severe unilateral headaches related to a small, unruptured ophthalmic artery aneurysm, who experienced complete headache cessation following endovascular coiling.

BACKGROUND

Small unruptured intracranial aneurysms are generally managed and followed conservatively due to minimal risk of rupture. Headaches are frequently reported in patients with intracranial aneurysms, but these aneurysms are typically considered incidental and unrelated, given the undefined association between headaches and most aneurysms.

CONCLUSION

There may be some unruptured intracranial aneurysms that can cause intractable headaches and warrant interventional treatment. Future prospective studies are needed that compare pre- and post-procedure headache character and diagnosis, aneurysm characteristics such as size, location, orientation, and shape, type of aneurysm repair with materials used, and other potential risk factors for worsening post-procedure headache in order to better predict headache association to aneurysms, as well as outcomes following endovascular aneurysm treatment.

Ophthalmic artery aneurysm: potential culprit of central retinal artery occlusion

Central retinal artery occlusion (CRAO) is one of the most devastating ophthalmic emergencies, causing acute painless visual loss in the affected eye. We describe the first case of acute non-arteritic CRAO associated with peripheral ophthalmic artery aneurysm and its clinical course after intra-arterial thrombolysis therapy. This case suggests that ophthalmic artery aneurysm can be the cause of CRAO and should be included in the differential diagnosis of CRAO.