Intracranial Aneurysms of Neuro-Ophthalmologic Relevance

Flow diversion for compressive unruptured internal carotid artery aneurysms with neuro-ophthalmological symptoms: a systematic review and meta-analysis

BACKGROUND

Data on the safety and efficacy of flow diverters (FD) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms (NOS) are scarce and comprise mainly small case series.

METHODS

We performed a search of three databases and included series with ≥10 patients, with unruptured aneurysms of the ICA and NOS, treated with FD. Random-effects analysis of treatment results and safety was performed.

RESULTS

A total of 22 studies reporting on 594 patients were included. Pooled proportions of NOS recovery, improvement, transient and permanent worsening were: 47.4% (95% CI 35.0% to 60.1%); 74.5% (95% CI 67.9% to 80.2%); 7.1% (95% CI 3.3% to 14.7%); and 4.9% (95% CI 3.2% to 7.4%), respectively. Rates of complete recovery and improvement in patients with isolated visual symptoms were 30.6% (95% CI 12.5% to 57.7%) and 56.6% (95% CI 42.3% to 69.9%). Isolated oculomotor symptoms recovered completely in 47.8% (95% CI 29.9% to 66.3%) and improved in 78% (95% CI 69.2% to 84.9%). Morbidity occurred in 5% (95% CI 2.8% to 9%) and mortality in 3.9% (95% CI 2% to 7.5%) of patients. An increased likelihood of symptom improvement was observed when treatment was performed early (<1 month) after symptom onset (OR=11.22, 95% CI 3.9% to 32.5%).

CONCLUSION

Flow diversion promotes recovery or improvement of compressive symptoms in a large proportion of patients but is associated with significant rates of morbidity and mortality. Transient and permanent NOS worsening is not uncommon. Early treatment is of utmost importance, as it increases the likelihood of symptom improvement more than 10-fold.

Elongated, finger-like ophthalmic segment aneurysms: Implications for selection of treatment modality

BACKGROUND

Microsurgical treatment of ophthalmic segment aneurysms often requires anterior clinoidectomy and optic nerve mobilization prior to successful clipping.

OBJECTIVE

We hypothesize that ophthalmic segment aneurysms that are elongated and finger-like grow unconstrained, lateral to the optic nerve. We note that this avoids the need for clinoid resection and optic nerve mobilization.

METHODS

Three cases with up-pointing aneurysms were reviewed. Patient and aneurysm characteristics were collected.

RESULTS

The first two patients with elongated ophthalmic segment aneurysms were found to have aneurysms growing lateral to the optic nerve. This allowed for straightforward treatment via microsurgical clipping without anterior clinoidectomy or division of the falciform ligament. The third patient presented with distortion of the optic chiasm superiorly and medially by a giant ventral ICA aneurysm. A concomitant ophthalmic aneurysm in this patient exhibited elongated morphology, with a high-resolution MRI demonstrating the patient's optic nerve was located inferior and medial to the ophthalmic artery aneurysm dome. This supports our hypothesis that an overriding optic nerve normally impedes vertical growth of ophthalmic segment aneurysms.

CONCLUSIONS

Ophthalmic segment aneurysms may acquire a round morphology when their growth is constrained superiorly by the optic nerve. Elongated ophthalmic segment aneurysms may be the result of growth lateral to the optic nerve. For these aneurysms, an anterior clinoidectomy is not required, and microsurgical clipping represents a straightforward treatment option.

Flow Diversion for ICA Aneurysms with Compressive Neuro-Ophthalmologic Symptoms: Predictors of Morbidity, Mortality, and Incomplete Aneurysm Occlusion

BACKGROUND AND PURPOSE

Flow diversion is an effective treatment for aneurysms of the ICA with compression-related neuro-ophthalmologic symptoms, especially when treatment is initiated early after symptom onset and aneurysm occlusion is complete. However, non-negligible complication rates have been reported. Our aim was to identify risk factors for morbidity/mortality and incomplete aneurysm occlusion.

MATERIALS AND METHODS

We performed a secondary analysis of a previous publication, which included all patients treated with flow diversion for an unruptured aneurysm of the ICA with compression-related symptoms.

RESULTS

Fifty-four patients with 54 aneurysms (48 women, 88.9%; mean age, 59.2 [SD, 15.9] years; range, 21-86 years) treated with flow diversion were included. We observed morbidity and mortality rates of 7.4% and 3.7%. Increasing age (OR per decade, 3.2; 95% CI, 1.23-8.49; P = .02) and dual-antiplatelet therapy with ticagrelor (OR, 13.9; 95% CI, 1.16-165.97; P = .04) were significantly associated with morbidity/mortality. After a median follow-up of 13.3 [SD, 10.5] months, the rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 74%, 14%, and 12%. Incomplete occlusion at follow-up was less frequently observed in aneurysms treated with additional coil embolization (OR, 0.1; 95% CI, 0.01-0.86; P = .04).

CONCLUSIONS

Although a promising treatment for compressive ICA aneurysms, flow diversion carries a relevant risk for complications and incomplete aneurysm occlusion. Our results may help identify patients in which flow diversion may not be the ideal treatment method. Additional coil embolization increased the likelihood of complete aneurysm occlusion at follow-up.

Contained Rupture of a Posterior Communicating Artery Aneurysm in a Patient With a Third Nerve Palsy

ABSTRACT

It is recommended that every patient with a new third nerve palsy undergo urgent neuroimaging (computed tomography angiography or magnetic resonance angiography) to exclude a posterior communicating artery aneurysm. Because of the novel coronavirus (COVID-19) pandemic, our institution noted a significant decline in the number of patients with aneurysmal subarachnoid hemorrhage presenting to the hospital. We report one such example of a patient who developed new-onset severe headache and vomiting and did not seek medical attention because of COVID-19. Two months later, she was noted to have ptosis during a routine follow-up and was found to have a complete, pupil-involving third nerve palsy. Computed tomography angiography was performed and revealed an irregular bilobed saccular aneurysm (7 × 9 × 5 mm) of the right posterior communicating (PComm) artery, but no acute hemorrhage was visible on CT. On MRI, immediately adjacent to the aneurysm, there was a small subacute hematoma in the right medial temporal lobe with surrounding vasogenic edema. This case had a fortunate and unique outcome as she had a contained hematoma adjacent to the ruptured PComm aneurysm and did not experience severe morbidity from the subarachnoid hemorrhage nor did she rebleed in the interval in which she did not seek care. This case highlights the importance of providing neuro-ophthalmic care even during a pandemic.

Flow diversion for internal carotid artery aneurysms with compressive neuro-ophthalmologic symptoms: clinical and anatomical results in an international multicenter study

BACKGROUND

Scientific data on the safety and efficacy of flow diverter stents (FDS) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms are scarce. We studied this subject in a retrospective international multicenter series, pooling data of 9 tertiary care neurointerventional departments.

OBJECTIVE

To investigate, in a retrospective, multicentric cohort of patients presenting with visual or oculomotor symptoms attributed to a compressive carotid artery in an unruptured intracranial aneurysm, the safety and efficacy profiles of FDS, by analyzing neuro-opthalmologic symptom evolution following FDS placement, complications, and aneurysm obliteration rates.

METHODS

All patients treated since 2015 with a FDS for an unruptured aneurysm of the ICA with signs of compressive cranial nerve symptoms (CN II, III, IV, VI) were included.

RESULTS

We treated 55 patients with 55 aneurysms; 21 (38.2%) patients had oculomotor and 15 (27.3%) visual symptoms only; 19 (34.5%) presented with a combination of both. Treatment-related morbidity/mortality occurred in 7.2% and 3.6%, respectively. At last imaging follow-up (13.1±10.5 months) rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 72%, 14%, and 14%, respectively. At last clinical follow-up after 13±10.5 months, 19/51 (37.3%) patients had recovered completely and 18/51 (35.3%) had recovered at least partially from their neuro-ophthalmological symptoms. In multivariable models, a longer delay between symptom onset and treatment was associated with higher odds for incomplete recovery and lower odds for any improvement (aOR 1.03 (95% CI 1.01 to 1.07), p=0.047 and 0.04 (0-0.81), p=0.020). Incomplete recovery was independently associated with older age and fusiform aneurysms.

CONCLUSION

FDS are effective to treat patients with compressive aneurysms of the ICA causing neuro-ophthalmological symptoms, especially when treatment is initiated early after symptom onset, and aneurysm occlusion is adequate. However, serious complications are not rare.

Treatment Outcomes of Cerebral Aneurysms Presenting with Optic Neuropathy: A Retrospective Case Series

Background:

Optic neuropathy due to an aneurysm is relatively rare, with only a few small case series on this topic, and no randomized trials having been published until now. As such, the functional prognosis and treatment for aneurysm-induced optic neuropathy remain controversial.

Objective:

We quantified optic nerve injuries using an objective index (the visual impairment score) and evaluated prognostic factors of postoperative visual function.

Materials and Methods:

Of 960 patients treated for an unruptured intracranial aneurysm, 18 (1.9%) patients had optic neuropathy. Visual acuity and visual field were assessed before surgery and 6 months’ postoperatively. Cases were classified on the basis of treatment modality (coil embolization or flow alteration [FA]) and prognostic factors of the two treatment groups.

Results:

Of the 18 patients with an intracranial aneurysm and optic neuropathy, 12 (67%) were treated using coil embolization and 6 (33%) were FA. Visual function improved after surgery in 8 patients (44%), 5 (42%) in the coil embolization group, and 3 (50%) in the FA group. The visual function remained stable after surgery in 6 (33%) patients and worsened in 4 (22%). Patients with an aneurysms <15 mm in size had a favorable outcome (P = 0.05).

Conclusions:

Surgical treatment improved vision in 44% of cases, with no difference in the prognosis of coil embolization and FA and no effect of the duration of symptoms on outcomes. Further, the prognosis of visual function recovery was better for aneurysms <15 mm in diameter.