Visual sequelae after consensus-based treatment of ophthalmic artery segment aneurysms: the Johns Hopkins experience

Retinal artery/arteriole occlusion risks after endovascular treatment for unruptured intracranial aneurysm

BACKGROUND

To evaluate the association between retinal artery/arteriole occlusion (RAO) and unruptured intracranial aneurysm (UIA).

METHODS

Incident UIA patients from a nationwide cohort (n=253 240) were categorised into three groups based on subsequent treatment: observation (n=208 993), microsurgical clipping (n=14 168) and endovascular treatment (EVT) groups (n=30 079). The incidence and the incident time of RAO were analysed. HRs of RAO and associated risk factors were evaluated. Additionally, a hospital cohort comprising 2569 consecutive UIA patients treated at a tertiary hospital was analysed with detailed clinical information of UIAs.

RESULTS

In the nationwide cohort analysis, the incidence of RAO was significantly higher in EVT group than in observation and clipping groups, especially within 60 days (early RAO (within 60 days): HR=4.00, 95% CI: 2.44 to 6.56); delayed RAO (after 60 days): HR=1.74, 95% CI: 1.13 to 2.68). Multivariable analysis showed that the presence of chronic kidney disease (p=0.009) and use of a balloon microcatheter during the procedure (p=0.013) were associated with a higher risk of RAO. In hospital cohort analysis, 11 (0.8%) cases of RAO occurred after EVT, whereas none occurred after microsurgical clipping (p<0.001). Patients with RAO were younger and received balloon microcatheters more frequently than their counterparts. Ten cases of RAO (90.9%) occurred in paraclinoid aneurysms, where EVT was preferred over microsurgical clipping.

CONCLUSIONS

Performing EVT for UIA may increase the risk of subsequent RAO. Care should be taken when treating paraclinoid aneurysms with balloon microcatheters.

Cisternal, Falciform, and Optic Canal Decompression Influencing Optic Nerve Biomechanics: A Microsurgical Anatomic Study

BACKGROUND

Questions remain regarding optic nerve (ON) physiology, mechanical compliance, and microvasculature, particularly surgical outcomes and atypical visual field defects associated with sellar/parasellar pathology (eg, tumors and aneurysms).

OBJECTIVE

To study the microsurgical/histological anatomy of each ON segment and corresponding microvasculature, calculate area of optic-carotid space at each decompression stage, and measure ON tension before/after compression.

METHODS

Five cadaveric heads (10 sides) underwent sequential dissection: (1) intradural (arachnoidal) ON dissection; (2) falciform ligament opening; (3) anterior clinoidectomy, optic canal decompression, and ON sheath release. At each step, we pulled the nerve superiorly/laterally with a force meter and measured maximal mobility/mechanical tension in each position.

RESULTS

Cisternal ON microvasculature was more superficial and less dense vs the orbital segment. ON tension was significantly lower with higher mobility when manipulated superiorly vs lateromedially. Optic-carotid space significantly increased in size at each decompression stage and with ON mobilization both superiorly and laterally, but the increase was statistically significant in favor of upward mobilization. At decompression step, upward pull provided more space with less tension vs side pull. For upward pull, each step of decompression provided added space as did side pull.

CONCLUSION

Opening the optic canal, falciform ligament, and arachnoid membrane decompresses the ON for safer manipulation and provided a wider optic-carotid surgical corridor to access sellar/parasellar pathology. When tailoring decompression, the ON should be manipulated superiorly rather than lateromedially, which may guide surgical technique, help prevent intraoperative visual deterioration, facilitate postoperative visual improvement, and help understand preoperative visual field deficits based on mechanical factors.

A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms

OBJECTIVE

Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings.

METHODS

The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications.

RESULTS

A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications.

CONCLUSIONS

Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

Altitudinal Visual Field Defects Following Diagnostic Transfemoral Cerebral Angiography

Transfemoral cerebral angiography (TFCA) has been increasingly used as diagnostic method for the evaluation of cerebral vessels. Ophthalmologic complication after TFCA has rarely been reported, and most complications are associated with an intraoperative thrombo-embolic event. We reported a patient who developed a superior altitudinal visual field defect one day after diagnostic TFCA. The ophthalmic exam revealed a prominent inferior optic disc edema, and the fluorescein angiographic showed the non-perfusion of the corresponding inferior sectoral optic disc. Diffusion-weighted MRI on the day following cerebral angiography revealed multiple focal scattered acute infarctions. Even one month after steroid pulse therapy, the superior nasal field defect remained with minimal improvement. We believe this case was consistent with an acute anterior ischemic optic neuropathy (AION) due to thrombo-embolism after TFCA. Ophthalmic examinations and a visual field test should be performed before and immediately after the TFCA, particularly in the case with a high risk of thromboembolic events.

Flow-diverting devices in the treatment of unruptured ophthalmic segment aneurysms at a mean clinical follow-up of 5 years

A shift toward the endovascular treatment of ophthalmic segment aneurysms is noticeable. However, it is not clear if the long-term treatment results improve with the development of endovascular methods. The aim of this study was to present the outcomes of the treatment of unruptured ophthalmic aneurysms using flow diverting devices (FDD) with or without coiling. This retrospective study included 52 patients with 65 UIAs treated in 2009–2016. The mean aneurysm size was 8.8 mm. Eight aneurysms were symptomatic. Therapeutic procedures included: 5 failed attempts, 55 first sessions with FDD deployment (bilateral procedures in 3) and 3 retreatment procedures. To cover 55 ICAs, 25 Silk, 26 Pipeline, 9 Fred and 1 Surpass FDD were used. FDD with coiling was applied in 19(29.2%), mainly for symptomatic and larger aneurysms. Mean radiological and clinical follow-up was 12 and 61 months, respectively. Postprocedural deterioration was noted in 3(5.8%) patients, but in long-term the modified Rankin Scale grades 0–2 were achieved in 98.1% of patients. One patient died from the treated aneurysm rupture (annual risk—0.07%). Raymond–Roy occlusion classification class I or II was achieved in 98.5% in the long term, with similar results in both groups. Complications occurred in 40.4% of patients and the most frequent were: imperfect FDD deployment (15%), failed attempt of FDD deployment (9.6%) and late FDD stenosis (9.6%). Flow-diverting devices, with additional coiling in selected cases, may offer a very high proportion of satisfactory outcomes. However, in our experience the high risk of complications remains.

Microsurgical Clipping Techniques and Outcomes for Paraclinoid Internal Carotid Artery Aneurysms

BACKGROUND

Microsurgical clipping of paraclinoid aneurysms presents unique technical challenges because of the anatomical complexity of the paraclinoid region.

OBJECTIVE

To analyze microsurgical clipping techniques, complications, and outcomes associated with paraclinoid aneurysms, with a focus on clip selection and clipping technique according to aneurysm location.

METHODS

From 1997 to 2016, 231 unruptured paraclinoid aneurysms from 216 patients were treated using microsurgical clipping. We retrospectively reviewed patient records to analyze clinical outcomes.

RESULTS

A total of 80 aneurysms (34.6%) were treated with simple clipping. Among them, fenestrated clips were used with superior hypophyseal artery (SHA) aneurysms, but curved clips were used with most other aneurysms. A total of 151 aneurysms (65.6%) were treated using multiple clips, including tandem clipping for ophthalmic artery (OphA) aneurysms, tandem angled-fenestrated clipping for SHA and ventral carotid aneurysms, stacked clipping for dorsal carotid aneurysms, and various techniques for clinoidal segment/carotid cave aneurysms. Postoperative angiography was performed in 214 aneurysms (92.6%), and complete obliteration was confirmed in 195 aneurysms (91.1%). Using the modified Rankin Scale (mRS), overall functional outcome was good (mRS 0-2) in 99.6% of patients, although 30 cases (13.0%) showed new postoperative visual deficits.

CONCLUSION

Surgical clipping of paraclinoid aneurysms is an excellent treatment modality with good clinical outcomes and acceptable complication rates, particularly in centers with large experience in the microsurgical management of cerebrovascular disorders. Appropriate clip selection and clipping techniques are required to perform complete and safe clipping.

Predictor of Visual Impairment Following Paraclinoid Aneurysm Surgery: Special Consideration of Surgical Microanatomy Related to Paraclinoid Structures

BACKGROUND

Microsurgical clipping with extradural anterior clinoidectomy (EDAC) for paraclinoid aneurysm is an established technique with good angiographic outcomes, although postoperative worsening of visual acuity remains a concern. Multiple reports show visual acuity deteriorating after clipping, yet the cause remains unclear.

OBJECTIVE

To analyze results of asymptomatic paraclinoid aneurysm surgeries treated with EDACs, specifically focusing on the microanatomy of paraclinoid structure dissection. This determined the causes of delayed visual impairment and microsurgical indications.

METHODS

Results of the treatment with EDAC of 94 patients with cerebral aneurysm and normal preoperative visual acuity but also full visual fields were retrospectively analyzed.

RESULTS

The mean aneurysm size was 6.2 (±3.3) mm. Clipping was performed in 87 cases and trapping in 7 cases. Complete angiographic occlusion was observed in 91 patients. In 26 cases, a postoperative visual deficit occurred. A total of 20 cases exhibited partial visual field deficits, including 5 who were asymptomatic. Visual deficits were only detectable by postoperative ophthalmologic testing. Six showed light perception impairment or blinding. Of the 15 patients with symptomatic partial visual field deficits, 5 showed improvement at follow-up. Visual deficits persisted in 22 patients at the last follow-up. Multivariate logistic regression analysis revealed that medial projecting aneurysm (adjusted odds ratio [OR]: 10.43) and the opening of the carotidoculomotor membrane (adjusted OR: 5.19) were significantly related to visual impairment.

CONCLUSION

Excess dissection of carotidoculomotor membranes causes postoperative delayed visual worsening. For treating small, asymptomatic paraclinoid aneurysms, carotidoculomotor membranes should not be opened, and microsurgical clipping should not be performed for preoperative asymptomatic medial projecting aneurysms.

Visual Outcomes after Surgery for Paraclinoid Aneurysms: A Fujita Experience

INTRODUCTION

The surgical strategies for clipping of paraclinoid aneurysms are diverse. These aneurysms are unique in their location, as they closely abut the anterior clinoid process (ACP) and the optic nerve. The ultimate goal of clipping encompasses the exposure of neck of the aneurysm which is seldom complete without the manipulation of optic nerve and the ACP. This manipulation may result in disturbances of vision postoperatively. We analyze our results of visual outcomes in the surgery for paraclinoid aneurysms in this retrospective study.

MATERIALS AND METHODS

All patients with paraclinoid aneurysms who underwent surgery from June 2014 to June 2019 were included in the study. Surgical procedure was uniform in all patients which included anterior clinoidectomy and clipping of aneurysms as per the Bantane protocol. Glasgow Outcome Scale as well as vision was assessed at discharge and at 1 month and 6 months.

RESULTS

There were 77 cases of paraclinoid aneurysms operated during the abovementioned period. All patients had no symptoms related to vision preoperatively. Visual deterioration was noted in two patients. All patients were discharged with a good outcome on the Glasgow Outcome Scale.

CONCLUSION

Paraclinoid aneurysm has a good outcome when treated with surgery. The visual deterioration following surgery can be minimized with extradural anterior clinoidectomy and careful handling of the vessels and nerve.

Limited Indications for Clipping Surgery of Paraclinoid Aneurysm Based on Long-Term Visual Morbidity

OBJECTIVE

Clipping of paraclinoid aneurysm is still challenging because of poor visual morbidity. The extradural temporopolar approach was applied to clip paraclinoid aneurysms, with the expectation of reducing visual morbidity. Factors related to poor visual morbidity were evaluated, to assess the results for clipping of paraclinoid aneurysms.

METHODS

A series of 40 unruptured paraclinoid aneurysms in 38 patients were clipped via extradural temporopolar approach. Preoperative and postoperative states of visual cognitive function and radiological outcomes were investigated. Aneurysms were classified into dorsal type or non-dorsal type, and small (<9 mm) or not-small (≥9 mm), respectively, to identify factors correlated with visual morbidity.

RESULTS

Complete clipping rate was 90.0% without any recurrence (mean: 5.2 years). Visual morbidity was unexpectedly high at 28.9%, including 2.7% of blindness immediately after the operation, and 23.7% and 2.7% at the final examination (mean: 3.6 years). Multivariate analysis showed aneurysm size was significantly correlated with worse visual outcome. Visual morbidity was 13.3% and 11.1% for dorsal and the non-dorsal small aneurysms, respectively, and all these cases showed visual field defect limited to the nasal quadrant without decreased visual acuity. In contrast, the non-dorsal not-small aneurysms showed significantly worse visual morbidity (60%) with decreased visual acuity.

CONCLUSIONS

Clipping via extradural temporopolar approach can achieve durable treatment for small unruptured paraclinoid aneurysms with acceptable visual morbidity. Visual morbidity of the not-small non-dorsal type, however, was poor. The indications for clipping of paraclinoid aneurysm should be limited to small aneurysms, especially the dorsal type in young patients.

An Anatomic Feasibility Study for Revascularization of the Ophthalmic Artery, Part I: Intracanalicular Segment

BACKGROUND

The anatomico-functional complexity of the ophthalmic segment aneurysms is attributable to the presence of critical neurovascular structures in the surgical field. Surgical clipping of the ophthalmic artery (OpA) aneurysms can result in postoperative visual deficit due to the complexity of the aneurysm, vasospasm, or optic nerve manipulation. In this study, we aimed to characterize the feasibility of an intracanalicular OpA (iOpA) revascularization with 2 donor vessels: an intracranial-intracranial (IC-IC) bypass using the anterior temporal artery (ATA) and an extracranial-intracranial (EC-IC) bypass using the superficial temporal artery (STA). We further discuss their potential role in "unclippable" OpA aneurysms.

METHODS

Twenty cadaveric specimens were used to evaluate the operative exposure of the intradural and intracanalicular OpA segments using an extradural-intradural intracanalicular approach. The arterial caliber and length at the anastomotic sites and required donor artery lengths were measured. The feasibility of the bypass using both donors was assessed.

RESULTS

The average length of the intradural and intracanalicular segment of the OpA was 9.5 ± 1.6 mm. The mean caliber of the iOpA was 1.5 ± 0.2 mm. The mean ATA length required for an ATA-OpA anastomosis was 26.7 ± 8.9 mm, with a mean caliber of 1.0 ± 0.1 mm. The mean length of STA required for the bypass was 89.9 ± 9.7 mm, with a mean caliber of 1.92 ± 0.4 mm.

CONCLUSIONS

This study confirms the feasibility of iOpA revascularization using IC-IC and EC-IC bypasses. These techniques could potentially be used for prophylactic or therapeutic neuroprotection from retinal ischemic injury while treating complex OpA aneurysms, infiltrative tumors, or intraoperative arterial injuries.

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

OBJECTIVE

Paraclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%-40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling.

METHODS

The authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention.

RESULTS

A total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03).

CONCLUSIONS

In a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.

Microsurgical clipping of ophthalmic artery aneurysms: surgical results and visual outcomes with 208 aneurysms

OBJECTIVEWhile most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms.METHODSResults from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed.RESULTSDespite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0-2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits.CONCLUSIONSThe most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially decrease the incidence of delayed visual deficits. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.

Vision outcomes in patients with paraclinoid aneurysms treated with clipping, coiling, or flow diversion: a systematic review and meta-analysis

OBJECTIVE

Patients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but flow diversion (FD) has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decompress the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performed a meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment.

METHODS

A systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination findings were also acceptable.

RESULTS

Thirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vision in these patients was classified as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%–50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%–68%) of patients after clipping, 49% (95% CI 38%–59%) after coiling, and 71% (95% CI 55%–84%) after FD. Vision worsened in 11% (95% CI 7%–17%) of patients after clipping, 9% (95% CI 2%–18%) after coiling, and 5% (95% CI 0%–20%) after FD. New visual deficits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%–3%) for clipping, 0% (95% CI 0%–2%) for coiling, and 0% (95% CI 0%–2%) for FD.

CONCLUSIONS

To the authors’ knowledge, this is the first meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a significant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These findings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.

Direct Surgery of Previously Coiled Large Internal Carotid Ophthalmic Aneurysm for the Purpose of Optic Nerve Decompression

Background Progressive visual loss after coil embolization of a large internal carotid ophthalmic aneurysm has been widely reported. It is generally accepted that the primary strategy for this complication should be conservative, including steroid therapy; however, it is not well known as to what approach to take when the conservative therapy is not effective.

Case Presentation We report a case of a 55-year-old female presenting with progressive visual loss after the coiling of a ruptured large internal carotid ophthalmic aneurysm. As the conservative therapy had not been effective, we performed neck clipping of the aneurysm with optic canal unroofing, anterior clinoidectomy, and partial removal of the embolized coils for the purpose of optic nerve decompression. After the surgery, the visual symptom was improved markedly.

Conclusions It is suggested that direct surgery for the purpose of optic nerve decompression may be one of the options when conservative therapy is not effective for progressive visual disturbance after coil embolization.

Central Retinal Artery Occlusion after the Endovascular Treatment of Unruptured Ophthalmic Artery Aneurysm: A Case Report and a Literature Review

Endovascular coil embolization for ophthalmic artery (OphA) aneurysms has a risk of occlusion of the OphA, which can lead to loss of vision. The authors report a patient with unruptured OphA aneurysm which treated with endovascular coiling and were complicated by blindness due to OphA thromboembolic occlusion after the procedure. The OphA successfully recanalized using local intra-arterial fibrinolysis with complete regain of visual acuity. The risk of visual loss due to thromboembolic complications cannot be ignored during endovascular coiling of the OphA aneurysm despite of good retrograde flow during OphA occlusion test using a balloon catheter. Rapid intervention is required for recovering visual disturbance in such a situation.

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.

Endovascular treatment of unruptured ophthalmic artery aneurysms: clinical usefulness of the balloon occlusion test in predicting vision outcomes after coil embolization

BACKGROUND

Endovascular coil embolization for ophthalmic artery (OphA) aneurysms has the latent risk of occlusion of the OphA during the procedure, which can lead to loss of vision. We report clinical and angiographic results of endovascular treatment of OphA aneurysms together with the efficacy of the balloon occlusion test (BOT).

METHODS

From August 2005 to December 2013, 31 consecutive patients with 33 OphA aneurysms were treated in our institution. The patients were classified into two groups according to the location of the OphA within the aneurysmal sac. The BOT was performed in 28 patients using a hypercompliant balloon before endovascular coiling. Collateral circulation between the external carotid artery and the OphA was examined and visual function tests were performed before and after treatment. Patient demographics, angiographic and clinical outcomes were reviewed.

RESULTS

Among the 28 patients who underwent the BOT, intact collateral circulation was demonstrated in 26 (92.9%) patients and complete occlusion of the OphA was obtained in three patients after coiling. Retrograde filling of the OphA with choroidoretinal blush was observed on post-procedural angiography and no specific visual symptoms were reported during the follow-up period. Complete embolization was achieved in 30 lesions (96.8%) and only five patients (16.1%) had minor recanalization.

CONCLUSIONS

Endovascular treatment of OphA aneurysms can be performed safely and effectively in conjunction with BOT. The BOT may give useful information to predict visual outcome in patients whose OphA is likely to be threatened by the coiling procedure and to determine the optimal treatment strategy.

Neuro-ophthalmic presentation and surgical results of unruptured intracranial aneurysms—prospective Helsinki experience of 142 patients

OBJECTIVE

To assess prospectively neuro-ophthalmic findings associated with unruptured intracranial aneurysms and treatment morbidity and to identify factors predicting these findings.

METHODS

Patients admitted to Helsinki University Central Hospital and treated surgically or endovascularly during 2011 underwent a neuro-ophthalmic examination, including formal visual field testing, before operation, at discharge, and 2-4 months and ≥6 months postoperatively. Univariate and multivariate analysis was used to identify factors predicting eye movement disorders.

RESULTS

Study participants included 142 patients with 184 treated aneurysms: 7 (5%) had a third, fourth, or sixth nerve palsy or skew deviation preoperatively, and 16 (11%) had a third, fourth, or sixth nerve palsy or skew deviation postoperatively; the frequency was 8 (6%) at the last follow-up evaluation. Other findings included compressive optic neuropathy (n = 4), ischemic optic neuropathy (n = 1), Weber syndrome (n = 3), Benedikt syndrome (n = 1), and Wallenberg syndrome (n = 1). Of the 140 survivors at 6 months, 7 (5%) presented with visual field defects resulting from the aneurysm or its treatment. In the best bivariate model, factors independently predicting postoperative eye movement disorders were aneurysm location in the posterior circulation with an odds ratio of 142.02 (95% confidence interval = 20.13-1002.22) and aneurysm size (odds ratio = 1.28 for each 1-mm increase in diameter, 95% confidence interval = 1.12-1.47).

CONCLUSIONS

Management of unruptured intracranial aneurysms is fairly safe from a neuro-ophthalmic perspective, with some treatment-related morbidity being transient and minor. Although rare, an irreversible deficit is possible and should be taken into account when considering preventive treatment.

Vision outcomes and major complications after endovascular coil embolization of ophthalmic segment aneurysms

BACKGROUND AND PURPOSE

As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size, they can compress the optic nerve, prompting patients to present with visual disturbances. The purpose of this article is to describe the clinical and angiographic results with an emphasis on visual outcomes following the endovascular treatment of ophthalmic segment ICA aneurysms.

MATERIALS AND METHODS

The records of 1254 patients who presented for endovascular treatment of a cerebral aneurysm were retrospectively reviewed to identify 65 consecutive patients who underwent coil embolization of an ophthalmic segment ICA aneurysm. The clinical records, treatment reports, and imaging were reviewed with a focus on visual outcomes.

RESULTS

Twenty-two of the 65 patients (34%) who presented for treatment of an ophthalmic aneurysm reported a visual disturbance at presentation. Fifteen of the 22 patients (68%) experienced an improvement in their symptoms after treatment. Overall, patients with visual symptoms were significantly more likely to benefit from treatment than to have a decline in vision (P = .03). The overall morbidity was 4%, and mortality was 0%. The retreatment rate was high at 30%, though this was disproportionately weighted by an 86% retreatment rate in patients with ruptured aneurysms.

CONCLUSIONS

Patients with visual symptoms attributable to ophthalmic segment ICA aneurysms undergoing endovascular coil embolization were statistically more likely to experience an improvement in their vision than to have worsening or unchanged vision. Coiling was associated with a low morbidity rate, though an elevated retreatment rate.

Neuro-ophthalmic effects of stenting across the ophthalmic artery origin in the treatment of intracranial aneurysms

OBJECT.: The benefits of treating intracranial aneurysms in the region of the anterior visual pathways are well understood. However, the adverse effects of endovascular stenting across the ophthalmic artery have received little attention. The authors reviewed their experience with patients who had stents deployed across the ophthalmic artery origin.

METHODS

Patients' medical charts and imaging studies were reviewed to identify all patients with a non-flow diverting stent deployed over the ophthalmic artery origin for the treatment of intracranial aneurysms. All patients with neuro-ophthalmic complaints were referred for formal ophthalmological evaluation.

RESULTS

A total of 104 consecutive patients with 106 aneurysms were identified to meet criteria for inclusion in the study cohort. Preoperatively, 30 patients (29%) described headache symptoms and 32 patients (31%) reported visual complaints. Of the patients with preoperative headaches, 15 (54%) of 28 patients for whom follow-up was available experienced improvement in their symptoms. Of the patients with preoperative visual complaints, improvement was noted in 11 (41%) of the 27 patients for whom follow-up was available, 9 (33%) of 27 patients reported no change in visual symptoms, and 7 (26%) of 27 patients reported progression of symptoms. Visual field defects developing posttreatment were noted to occur in 8 (7.7%) of 104 patients: 3 with immediate postoperative retinal infarcts, 1 with perioperative hemianopia that resolved by the time of discharge, 1 with a subjective visual field defect, 1 with subjective migratory visual field defects, and 2 with nonspecific visual symptoms. Compressive symptoms from aneurysm mass effect were noted in 6 patients preoperatively, with 4 of those patients experiencing persistent worsening, resolution in 1 case, and no change in 1 case. One patient developed a novel cranial nerve palsy from mass effect in the immediate postoperative period.

CONCLUSIONS

Deployment of stents across the ophthalmic artery origin for the treatment of intracranial aneurysms appears to be relatively safe with regard to visual outcomes. Neuro-ophthalmic complaint resolution rates were comparable to endovascular procedures that do not employ stents, with headache resolution rates comparable to coil-only aneurysm obliteration and low rates of retinal ischemic events. For patients presenting with mass effect, stent-assisted coiling appears to be less effective than microsurgery with decompression for relief of compressive symptoms.

The minipterional craniotomy for anterior circulation aneurysms: initial experience with 72 patients

BACKGROUND

The pterional craniotomy is well established for microsurgical clipping of most anterior circulation aneurysms. The incision and temporalis muscle dissection impacts postoperative recovery and cosmetic outcomes. The minipterional (MPT) craniotomy offers similar microsurgical corridors, with a substantially shorter incision, less muscle dissection, and a smaller craniotomy flap.

OBJECTIVE

To report our experience with the MPT craniotomy in select unruptured anterior circulation aneurysms.

METHODS

From January 2009 to July 2013, 82 unruptured aneurysms were treated in 72 patients, with 74 MPT craniotomies. Seven patients had multiple aneurysms treated with a single MPT craniotomy. The average patient age was 56 years (range: 24-87). Aneurysms were located along the middle cerebral artery (n = 36), posterior communicating (n = 22), paraophthalmic (n = 22), choroidal (n = 1), and dorsal ICA segments (n = 1). The MPT craniotomy utilized an incision just posterior to the hairline and a single myocutaneous flap.

RESULTS

The average aneurysm size was 5.45 mm (range: 1-14). There were no instances of compromised operative corridors requiring craniotomy extension. Three significant early postoperative complications included epidural and subdural hematomas requiring evacuation, and a middle cerebral artery infarction. Average length of hospitalization was 3.96 days (range: 2-20). Two patients required reoperation for wound infections. Average follow-up was 421 days (range: 5-1618). Minimal to no temporalis muscle wasting was noted in 96% of patients.

CONCLUSION

The MPT craniotomy is a worthwhile alternative to the standard pterional craniotomy. There were no instances of suboptimal operative corridors and clip applications when the MPT craniotomy was utilized in the treatment of unruptured middle cerebral artery and supraclinoid internal carotid artery aneurysms proximal to the terminal internal carotid artery bifurcation.

Return of visual function after bilateral visual loss following flow diversion embolization of a giant ophthalmic aneurysm due to both reduction in mass effect and reduction in aneurysm pulsation

Large and giant paraclinoid aneurysms are challenging to treat by either surgical or endovascular means. Visual dysfunction secondary to optic nerve compression and its relationship with aneurysm size, pulsation and thrombosis is poorly understood. We present a patient with a giant paraclinoid aneurysm resulting in bilateral visual loss that worsened following placement of a Pipeline Embolization Device and adjunctive coiling. Visual worsening occurred in conjunction with aneurysm thrombosis, increase in maximal aneurysm diameter and new adjacent edema. Her visual function spontaneously improved in a delayed fashion to better than pre-procedure, in conjunction with reduced aneurysmal mass effect, size and pulsation artifact on MRI. This report documents detailed ophthalmologic and MRI evidence for the role of thrombosis, aneurysm mass effect and aneurysm pulsation as causative etiologies for both cranial nerve dysfunction and delayed resolution following flow diversion treatment of large cerebral aneurysms.

Continued Concern About Parent Vessel Steno-Occlusive Progression With Onyx HD-500 and the Utility of Quantitative Magnetic Resonance Imaging in Serial Assessment

BACKGROUND:

Onyx HD-500 is a liquid embolic used to treat intracranial aneurysms.

OBJECTIVE:

To determine the incidence of parent vessel stenosis and the management strategy for these patients.

METHODS:

Medical records of patients treated with Onyx HD-500 between 2008 and 2011 were retrospectively reviewed. Clinical and radiographic evaluations were assessed. Quantitative magnetic resonance angiography and NOVA (VasSol, Chicago, Illinois) images were reviewed for patients in whom these examinations were acquired.

RESULTS:

Seventeen patients underwent treatment of unruptured internal carotid artery aneurysms. Three patients (17.6%) developed visual symptoms after the procedure: 2 permanent and 1 transient. Four patients (23.5%) developed delayed internal carotid artery stenosis at the 6- to 8-month follow-up angiography, despite a standard antiplatelet regimen with confirmed sensitivities to aspirin and clopidogrel. Quantitative magnetic resonance angiography was obtained in all patients with stenosis to guide treatment. One patient progressed to complete but asymptomatic internal carotid artery occlusion. The second and third patients had asymptomatic stenosis of 40% and 70%, respectively, both of which resolved on follow-up angiography. The fourth patient developed critical stenosis distal to the aneurysm neck. Quantitative magnetic resonance angiography demonstrated adequate flow in the first 3 patients and decreased flow in the fourth patient, necessitating angioplasty and stenting. Prolonged dual antiplatelet regimens were continued in 2 of the 4 patients, 1 with progression of stenosis and 1 with improvement of stenosis.

CONCLUSION:

We observed a higher rate of parent vessel steno-occlusive progression after aneurysm embolization with Onyx HD-500 than reported in the literature, despite overall low morbidity. Quantitative vessel flow imaging was useful in subsequent medical management and decision making to perform therapeutic angioplasty/stenting to preserve flow.