Case report: saccular aneurysm of the intraorbital ophthalmic artery

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.

Balloon Occlusion Testing to Assess Retinal Collateral and Predict Visual Outcomes in the Management of a Fusiform Intraorbital Ophthalmic Artery Aneurysm: Technical Note and Literature Review

BACKGROUND AND IMPORTANCE

Aneurysms of the ophthalmic artery (OA) within the orbit and optic canal are extremely rare. Given the peripheral location of these aneurysms and the fact that most are fusiform, parent artery occlusion is preferred for symptomatic aneurysms. However, the impact of OA occlusion on vision is not always innocuous. Balloon occlusion testing (BOT) of the OA has the potential to gauge the possibility of visual compromise, in addition to assessing collaterals. While BOT has been assessed for carotid artery occlusion, its role in OA occlusion has not been well defined.

CLINICAL PRESENTATION

We describe a patient with a 6-mm intracanalicular OA aneurysm who was treated with endovascular coil embolization of the aneurysm and occlusion of the parent artery. We performed a 30-min balloon occlusion test, in which we verified intact visual and neurological function. Collateral vascularity was confirmed. Complete occlusion was achieved and the patient recovered with intact visual and neurological function. We provide a review of literature pertaining to parent artery occlusion of OA aneurysms that occur within optic canal and orbit. A brief note on anatomy of OA and collaterals is provided.

CONCLUSION

Endovascular parent artery occlusion is an effective treatment for OA aneurysms that occur in optic canal and orbit. Assessment of effect of occlusion on vision is important. BOT can assess this and provide valuable information. Recovery or preservation of visual function is highly dependent on preoperative visual status.

Peripheral ophthalmic artery aneurysm

Generally speaking, the term "ophthalmic aneurysms" refers to carotid-ophthalmic aneurysms, which arise from the internal carotid artery (ICA) wall at or around the origin of the ophthalmic artery (OA). In contrast, aneurysms arising from the OA stem or its branches, separate from the ICA are called peripheral OA aneurysms (POAAs). POAAs are a rare entity, which clinical features and natural course are not fully understood. A comprehensive literature review of reported aneurysms involving each segment of the OA was undertaken. The demographics, aetiology, clinical manifestations and treatment of reported POAAs are discussed. Of 35 retrieved cases, ten involved the intracranial segment, two were fusiform aneurysms in the optic canal, 17 arose from the intraorbital segment, and 6 involved either the lacrimal or the anterior ethmoidal branches. In 34 cases, clinical details were available; 18 patients experienced moderate to severe visual impairment including blindness, while seven patients had improvement in visual acuity as a result of surgical treatment. The present clinical review reveals that aneurysms of the OA stem and lacrimal branch are potentially threatening to visual acuity, while intracranial segment and anterior ethmoidal aneurysms can rupture and cause subarachnoid or intraparenchymal haemorrhage. Surgical intervention is mandatory in symptomatic cases to prevent visual deterioration or treat aneurismal rupture; alternatively, for small incidental POAAs "watchful waiting" may be indicated.

Bilateral intra-orbital ophthalmic artery aneurysms

CLINICAL DETAILS

A 52-year-old man presented with neck pain, nausea and vomiting (Hunt-Hess grade 1). CT scan showed subarachnoid hemorrhage. Cerebral angiography showed multiple arterial aneurysms (right communicating posterior, right anterior choroid, left pericallosal, intraorbital ophthalmic bilaterally). All aneurysms but intraorbital ophthalmic ones were treated with endovascular embolizations. As the intraorbital aneurysms were asymptomatic no treatment was performed. The patient was dismissed without any neurological deficits.

DISCUSSION

Intraorbital ophthalmic aneurysms are very uncommon, with extremely rare rupture. No treatment is indicated when the aneurysm is unruptured and asymptomatic. Surgical treatment is advised only after rupture or symptomatic mass effect.

Fusiform intracanalicular ophthalmic artery aneurysm; case report and review of literature

A 35-year-old man's vision had progressively deteriorated over a 3-month period. His left visual acuity was 5/20. Enhanced orbital computed tomographic (CT) scans revealed a fusiform dilatation of the ophthalmic artery in the left optic canal. Cerebral Angiography revealed a fusiform aneurysm on the left ophthalmic artery in the optic canal, measuring 6.2 x 4.6 mm in size. Four days after admission, visual acuity dropped to hand-motion. Endovascular treatment was chosen and a microcatheter was guided into the proximal segment of the ophthalmic artery. Using 4 detachable coils, parent artery occlusion was done. Three months after the intervention, the visual acuity in his left eye improved to 20/20. Dramatic recovery of visual acuity is exceptional with an ophthalmic artery trunk aneurysm. When an occlusion of the proximal ophthalmic artery is the only treatment option in such a situation, the endovascular occlusion of the proximal ophthalmic artery is quite feasible in the sense that it does not require any optic nerve manipulation.

Clinical Case Notes. Intraorbital ophthalmic artery aneurysms

Angiographically documented aneurysms of the intraorbital ophthalmic artery are extremely rare. Two cases are presented of intra-orbital ophthalmic artery aneurysms, both associated with arteriovenous malformation (AVM). There have only been isolated reports documenting this combination of vascular anomalies. In the first case, the aneurysm was treated conservatively and in the second case, after staging angiography and interventional embolization, the aneurysm was removed along with the associated AVM. The clinical presentation, pathogenesis and management of this rare combination of vascular anomalies is briefly discussed.

Ruptured aneurysm of the ophthalmic artery trunk demonstrated by three-dimensional rotational angiography: case report

OBJECTIVE AND IMPORTANCE

Aneurysms arising from the ophthalmic artery are extremely rare, compared with carotid-ophthalmic aneurysms arising from the wall of the internal carotid artery. We present a very unusual type of aneurysm arising from the ophthalmic artery itself.

CLINICAL PRESENTATION

A 54-year-old man presented with a sudden onset of headache and was transferred to a local hospital. Computed tomography demonstrated subarachnoid hemorrhage around the left anterior clinoid process, but digital subtraction angiography failed to localize the source of the hemorrhage. The patient was referred to our hospital for further evaluation and treatment. Conventional cerebral angiography did not reveal the source of the hemorrhage, but three-dimensional rotational angiography clearly demonstrated an aneurysm arising from the ophthalmic artery trunk, apart from the internal carotid artery.

INTERVENTION

The patient underwent microsurgical clipping of the aneurysm via a left pterional craniotomy. The aneurysm originated from the bifurcation of the ophthalmic artery and a perforating artery to the optic nerve. The aneurysm was successfully obliterated, and the postoperative course was uneventful.

CONCLUSION

This report is the first to describe a case of a ruptured aneurysm arising from the ophthalmic artery trunk. We discuss the clinical significance of an aneurysm at this site, as well as the role of three-dimensional rotational angiography in determining the source of subarachnoid hemorrhage.