Complete recovery from monocular blindness caused by aneurysmal compression to optic nerve--report of two cases

Cranial nerve palsies and intracranial aneurysms: A narrative review of patterns and outcomes

Background

Cranial nerve palsy (CNP) in patients with intracranial aneurysms (IAs) can impose significant burdens on a patient's quality of life. The literature has a paucity of reviews addressing patterns of overall reported cranial nerve (CN) involvement and outcomes in patients with IA.

Methods

The literature systematically reviewed CNP at presentation in the setting of IA using PubMed, Web-of-Science, and Scopus according to the PRISMA guidelines.

Results

Fifty-two studies reported a total of 513 patients with IA and 630 CNPs observed at presentation: oculomotor (58.25%), abducent (15.87%), optic (12.06%), trochlear (8.7%), and trigeminal (1.9%). Most common aneurysms are located in a posterior communicating artery (46%) and cavernous internal carotid artery (29.2%). Trends of CNP based on the rupture status of IAs showed that 80% were associated with unruptured IAs and 20% with ruptured IAs. Post-treatment of IA, 55% of patients had complete resolution of CNP, with most (89%; n = 134) resolving within the first 6 months. Stratified by CNP type: Complete resolution rate is 100% in CN VII-IX, 60% in CN VI, 59% in CN IV, 54% in CN III, 45% in CN V, and 43% in CN II.

Conclusion

In patients with cranial nerve palsies attributed to IAs, the location and rupture status of the aneurysm could determine the type and severity of the nerve palsy. Most patients experienced favorable outcomes in terms of their resolution and long-term function of the CNP after treatment of the IA.

Recurrent Fevers and Neuro-ophthalmic Disorders in a Mathematical Genius

Horner's syndrome coexisting with an ipsilateral fourth cranial nerve palsy is a rare occurrence and likely localises to pathology in the cavernous sinus. One such case may have occurred in the 18^th century affecting the renowned mathematician Leonhard Euler. A review of his biographies, eulogies, and three finely detailed facial portraits suggest that these two neuro-ophthalmic conditions, along with visual loss and a decades-long intermittent febrile illness, may have been the result of an orbital cellulitis and septic cavernous sinus thrombosis, from an underlying chronic brucellosis infection.

"Fountain Sign," a Basic Finding toward the Diagnosis of Partially Thrombosed Giant Aneurysm: Describing a Challenging Case and Literature Review

Although the occurrence of cerebral aneurysms in pediatric age group describes as rare, giant ones are more commonly be found than in adults. Insufficient epidemiological information, their association with other medical comorbidities, diagnostic pitfalls, complex surgical anatomy, and issues should be considered during surgery to make them difficult to diagnose and manage. We report a 6-year-old boy with presenting complaint of acute-onset headache without any other symptoms and a small area of intracerebral hemorrhage detected on initial computed tomography (CT) scan. Primary evaluations failed to result in a definite diagnosis, and delayed vascular studies suggested vascular malformation or an aneurysm as the causative factor of hemorrhage. Surgical exploration led to the diagnosis of a giant partially thrombosed aneurysm at the A2 segment of the left anterior cerebral artery and successful clipping. One of our findings on preoperative CT angiography, “fountain sign,” may be useful for the diagnosis of partially thrombosed aneurysms when active bleeding from the aneurysm has been ruled out. Fountain sign can be a useful finding in the diagnosis of partially thrombosed aneurysms. Vascular lesions should always be considered as the primary cause of intracranial hemorrhage in pediatrics despite negative initial studies. Therefore, close follow-up and using delayed and multimodality vascular evaluations are crucial for successful management.

Photophobia as the visual manifestation of chiasmal compression by unruptured anterior communicating artery aneurysm. Case report

A 37-year-old woman presented with photophobia without visual loss associated with chiasmal compression by an unruptured anterior communicating artery (AcomA) aneurysm. She had suffered progressive photophobia for one year. Neuroimaging indicated an AcomA aneurysm attached to the chiasm. Photophobia was resolved following clipping of the aneurysm. AcomA aneurysm should be considered in patients who experience photophobia without visual loss.

Vision salvage after resection of a giant meningioma in a patient with a loss in light perception

Clinical approaches to the surgical management of optic chiasm compression stress quick action, as several case series have demonstrated minimal vision restoration following aggressive decompression in patients presenting more than 3 days after the onset of blindness. The authors here report the case of a 48-year-old woman who presented with near-complete binocular vision loss but regained visual function following surgical removal of a giant planum-tuberculum meningioma, which was performed 8 days after a documented loss in light perception. The interval between the patient's vision loss and successful vision-restoring decompressive surgery is the longest recorded to date in the literature. This case shows the importance of aggressive decompression of mass lesions despite extended intervals of optic nerve dysfunction.

Surgical reversal of prolonged blindness from a metastatic neuroblastoma

BACKGROUND

Reports of tumor-related anterior visual pathway blindness that have resolved after surgical decompression are rare. The longest reported duration of tumor-related blindness completely reversed by optic nerve decompression is 3 days. We describe a pediatric patient with 7 days of no light perception who experienced reversal of blindness following tumor resection and optic nerve decompression.

CASE DESCRIPTION

A 33-month-old boy presented with a 4-day history of no light perception. Magnetic resonance imaging revealed a mass involving the sphenoid sinus, sella turcica, and clivus with significant optic nerve involvement. Loss of light perception and complete absence of a pupillary light reflex were documented for the next 72 h. A sluggish pupillary light reflex was regained 24 h after instituting intravenous steroids. An urgent bi-frontal craniotomy and optic nerve decompression were performed 7 days after the onset of blindness. Surgical pathology revealed metastatic neuroblastoma. Eleven days after optic nerve decompression, the child was able to count fingers and recognize faces and printed book characters.

CONCLUSION

Prolonged blindness secondary to tumor-related optic nerve compression may be reversible up to 1 week from onset in children presenting with no light perception.

Visual recovery after a year of craniopharyngioma-related amaurosis: report of a nine-year-old child and a review of pathophysiologic mechanisms

BACKGROUND

The probability of visual recovery in tumor-related optic neuropathy usually correlates with the severity and duration of optic pathway compromise. Recovery of visual acuity to normal levels is unexpected after profound loss of vision extending for a period of weeks and months.

METHODS

A 9-year-old girl who had neurosurgical resection of a craniopharyngioma compressing the optic chiasm and optic tract was followed up serially with neuroimaging and clinical examinations over a 6-year period.

RESULTS

Within 3 months of the diagnosis of craniopharyngioma, the girl's vision was reduced to no-light-perception blindness when she viewed with the more involved eye. The blindness correlated with an amaurotic (i.e., >3.6 log unit) relative afferent pupillary defect and an absence of any response when tested with visual field perimetry. After more than a year of total blindness and cessation of all neurosurgical and radiation therapy, visual acuity recovered to a normal level (20/25), the afferent pupillary defect improved, and sensitivity in a portion of the temporal hemivisual field was restored. In the follow-up that has extended for 5 years from the time of recovery, stability of the restored vision has been documented.

CONCLUSION

Children who have tumor-related loss of vision due to damage to the anterior visual pathways may be capable of recovery after intervals of blindness that would be considered irreversible in adults. The mechanism of the recovery in our patient may have been decompression-related restoration of axoplasmic flow, followed by gradual remyelination of visual fibers, which allowed reorganization of connections to the lateral geniculate nucleus to optimize synaptic transmission.

Compression of the visual pathway by anterior cerebral artery aneurysm

Visual failure is an uncommon presenting symptom of an intracranial aneurysm. It is even more uncommon in aneurysms arising from the anterior cerebral artery (ACA). We presented 2 patients with an aneurysm of the A1 segment of the anterior cerebral artery causing visual field defects. One patient presented with a complete homonymous hemianopia due to compression of the optic tract by a giant aneurysm of the proximal left A1 segment. The second patient had an almost complete unilateral anopia caused by compression of the optic nerve and chiasm by an aneurysm of the distal part of the A1 segment with a small chiasmatic hemorrhage and ventricular rupture.

Penetration of the optic chiasm by a ruptured anterior communicating artery aneurysm. Case report

There are few reports of anterior communicating artery aneurysms causing visual symptoms, and penetration of the optic chiasm by such aneurysms has not been reported. A 40-year-old man presented with the abrupt onset of left homonymous hemianopsia, right visual acuity disturbance (finger counting), and slight headache. Angiography disclosed a 7-mm anterior communicating artery aneurysm projecting inferiorly. After the neck of the aneurysm was clipped, the dome of the aneurysm was resected. The operation confirmed that the aneurysm had penetrated the right half of the optic chiasm and the thrombosed dome had also compressed the right optic tract. Although the aneurysm was successfully clipped, the visual disturbance persisted after surgery, suggesting that the damage to the visual pathways by aneurysm penetration was irreversible in this case.