Anterior communicating artery aneurysm related to visual symptoms

Anterior Communicating Artery Aneurysms: Surgical Strategy and Outcome based on Proposed Newer Classification

BACKGROUND

The ruptured anterior communicating artery aneurysm is the most frequent intra-cranial aneurysm treated at any neurosurgical department. These aneurysms arise from either the A1-A2-Acom artery junction or Acom artery. The surgical outcome depends on the age of the patient, time duration between ictus and surgery, and Hunt and Hess grade at admission. In this article, we intend to analyze the surgical outcome based on our proposed classification with our overall experience of Acom aneurysm.

METHODS

A retrospective review of our surgical database with 250 patients of ruptured Acom was done, and the location, morphology, and direction of aneurysm, along with other clinical parameters including the demographic profile, radiological findings, and intra-operative details, were studied. We classified the Acom based on both site of origin and morphology (Type I, junctional on the dominant side; Type II, fusiform with an ill-defined neck and branching pattern; Type III, saccular true Acom A) and secondarily as described in the literature on the basis of the direction of fundus (Type A-E). The clinical parameters were compared among the above groups using Fischer-exact and one-way analysis of variance test.

RESULTS

A total of 250 patients (M: F =113:137) were included (mean age 52.1 ± 11.5 standard deviation years). 55.2% patients had left A1 dominance. Type I Acom A was commonly found on the left dominant circulation (P = 0.00). The difference in aspect ratio of Type I (2.0 ± 0.8) and Type II (1.8 ± 0.52) aneurysms was insignificant (P = 0.28). However, a significant difference in post-operative vasospasm among different types of aneurysms was found (P < 0.05). The Type I Acom A were anteriorly directed, while Type II and III were posteriorly directed (P = 0.001). The mean follow-up of the study was 44.4 ± 25.7 months, with age (P = 0.007) and Hunt and Hess grade (P = 0.001) at admission correlating with surgical outcome.

CONCLUSION

Classifying the Acom A pre-operatively based on site and morphology, location, and direction of fundus helps in surgical planning and prognosis. The junctional 'Type IA aneurysms' are most common and possess a high intra-operative rupture rate. The anteriorly directed aneurysms have a better prognosis, and visual complaints are usually associated with anterior-inferiorly directed aneurysms.

Improvement of Visual Field Defects after Neuroembolization Treatment of Intracranial Aneurysms. Case Reports

PURPOSE

Intracranial aneurysms and their hemorrhagic and thromboembolic complications represent a serious nosological unit that significantly endangers those afflicted. They are mostly asymptomatic until rupture occurs. In two case reports, we present our observations of young patients with impaired vision and headaches, in whom we found the presence of intracranial aneurysms.

OBSERVATIONS

Presentation of two case reports of patients who came to our department with impaired vision and headaches. The patients underwent a complete eye examination at our center, including a visual field examination. Based on the results of the examination, they were referred for  an imaging examination of the brain, which revealed the presence of intracranial aneurysms. The patients were subsequently sent to the interventional neuroradiology center, where they underwent a noninvasive endovascular neuroembolization procedure with flow diverter implantation. We continued to monitor the patients after the procedure and document the examination results up to 1 year after the procedure.

CONCLUSIONS AND SIGNIFICANCE

Thanks to the fast detection, diagnosis, and management of both patients, we prevented the occurrence of aneurysm rupture, thus a life-threatening complication. After endovascular procedures with flow diverter implantation, we observed a significant improvement in visual acuity as well as perimetric findings in both patients. When intracranial aneurysms are found within a week of the onset of eye symptoms and treated within three months, defects in the visual fields improved in our two patients within 6-12 months, and in one of the two patients the defects almost completely disappeared.

Small symptomatic anterior communicating artery aneurysms: report of three cases and literature review

PURPOSE

Given the anatomical relationship between the ACom complex and the optic nerve, small aneurysms of the ACom can present with visual symptoms.

CASE REPORTS

We summarize and illustrate the clinical course of three patients with symptomatic small ACom aneurysms and collect similar other cases reported.

RESULTS

Ten patients with small unruptured visually symptomatic anterior communicating artery aneurysms were found in the literature. Including three patients herein reported, the mean age at presentation was 56. The most common visual symptoms were bitemporal vision loss and/or a decrease in visual acuity.

CONCLUSION

Unruptured aneurysms of the anterior communicating artery can present with visual symptoms due to compression of optic pathways, even at a small size. Prompt recognition and treatment of such a condition are paramount as new onset of visual symptoms can signify impending rupture akin to small PCom aneurysms compressing the third nerve. We discuss a few pitfalls of clipping small ACom aneurysms compressing the optic nerve.

Complete bilateral blindness associated with ruptured anterior communicating artery aneurysm: A literature review and illustrative case

Background

Anterior communicating artery (AcomA) aneurysms are considered one of the most common intracranial aneurysms, contributing to approximately 40% of the subarachnoid hemorrhages related to aneurysmal rupture. Aneurysms of the anterior circulation are commonly present with visual defects varying in their nature according to the aneurysmal site. However, complete bilateral vision loss associated with AcomA aneurysms is a significantly rare finding. We are reporting a case of complete bilateral blindness in a patient with a ruptured AcomA aneurysm with a literature review.

Methods

We conducted a PubMed Medline database search by the following combined formula of subjects' headings: (((Intracranial Aneurysm [MeSH Terms]) AND (AcomA Aneurysm [Title/Abstract])) AND [(Vision loss OR Blindness [Text Word])) AND (case reports [Filter]). Additional articles were searched through the reference lists of the included articles.

Results

Our review yielded a total of five cases. All the present cases revealed unilateral blindness only, and their outcomes after treatment vary from recovery of vision to unchanged complete vision loss - none of the cases found in the literature presented with bilateral blindness.

Conclusion

AcomA aneurysms can be associated with visual loss in some cases. However, usually, the defect is unilateral. Studies of the visual defects, including potential bilateral complete blindness associated with rupture inferiorly, directed AcomA aneurysm, should be highlighted.

Scintillating scotoma following optic nerve compression caused by an unruptured anterior communicating artery aneurysm: a case report

Background

Scintillating scotoma caused by optic nerve compression by aneurysm is rare. We report a case of scintillating scotoma following optic nerve compression caused by an unruptured anterior communicating artery aneurysm.

Case presentation

A 64-year-old woman visited our department with a scintillating scotoma. Magnetic resonance imaging demonstrated no new lesions, although her previously diagnosed anterior communicating artery aneurysm had increased in size. Thus, we performed neck clipping. The operative view showed that the aneurysm compressed the right optic nerve. Her symptoms disappeared after the operation. These findings suggest that scintillating scotoma may be caused by compression of the optic nerve by the anterior communicating artery aneurysm.

Conclusion

Although scintillating scotoma is a common condition, aneurysms should be considered as a potential cause.

Recovery of Visual Loss Following Internal Trapping of Anterior Cerebral Artery (A1 Segment) for Partially Thrombosed Large Anterior Communicating Artery Aneurysm: A Case Report

A 60-year-old woman, who experienced progressive right visual loss, was diagnosed with an unruptured large cerebral aneurysm. Magnetic resonance imaging (MRI) and angiography revealed a large partially thrombosed anterior communicating artery (Acom) aneurysm. The aneurysmal neck was located at the junction of the left A1–A2 segments, and the aneurysmal dome communicated with the right A1–A2 junction by the Acom. Endovascular treatment using the flow alteration technique was selected. Following an oral antiplatelet therapy for 9 days, balloon test occlusion (BTO) of the medial portion of the left A1 segment was performed under local anesthesia. After confirming the tolerance of the BTO, internal trapping of the medial portion of the left A1 segment by detachable coils was performed following intra-aneurysmal coil embolization. Oral antiplatelet treatment was continued for 19 days postoperatively. Within 3 months following the operation, her right visual acuity dramatically improved to the original level. Owing to aneurysmal recanalization and the disappearance of the thrombus, the second and third embolization was performed through the Acom route, 4 months and 3 years following the first embolization, respectively, and followed up for an additional 7 years by MRI; no deterioration of her visual acuity and no aneurysmal recanalization was observed. Thus, endosaccular embolization combined with flow alteration is considered a useful alternative treatment for large and partially thrombosed Acom aneurysms.

Microsurgical Clip Suspension to Prevent Optic Neuropathy Following Ligation of Anterior Communicating Artery Aneurysm: A Technical Report and Surgical Video

Anterior communicating artery (ACoA) aneurysms are among the most common intracerebral aneurysms. Complications of ACoA aneurysm include subarachnoid hemorrhage, which may occur spontaneously or as a result of trauma. While prognosis of microsurgical clip ligation is excellent, iatrogenic afferent pupillary defect secondary to mechanical compression of the optic nerve by the clips is a known complication. Our report presents a case of a 59-year-old female status post resection of a pituitary macroadenoma one year ago with a three- to four-week history of progressively worsening headache found to have a 6.5 x 5.4 mm wide neck and irregularly dysplastic aneurysmal dilation of the ACoA. During the operation, two of the longer clips appeared to be touching the optic nerve and we utilized a clip suspension technique to relieve compression. This gently elevated and suspended the two clips up to the dura, allowing for a 2 mm gap between the optic nerve and clips. This maneuver relieved mechanical compression against the optic nerve and potentially mitigated the need for surgical re-exploration in the future. 

Prognostic Factors Influencing Outcome in Unruptured Anterior Communicating Artery Aneurysm after Microsurgical Clipping

Anterior communicating artery (A.com. A) aneurysm projection is an important factor in determining the outcome of aneurysm clipping. The objective of this study was to analyze the outcome of A.com.A aneurysm projection and prognostic factors influencing it and comparing them with Glasgow outcome scale. A retrospective analysis of 47 patients from hospital records who have got admitted in the Banbuntanke Hotokokai Hospital, Nagoya, Japan, from 2014 to 2017, with unruptured A.com.A aneurysm and subsequently operated in the hospital. Demographic factors such as age, sex, and associated with other aneurysms and the morphological characteristics such as aneurysm size, projection, and height were analyzed with postoperative complications and Glasgow outcome scale. Totally 47 cases have been operated in which 26 (55.3%) are female and 21 (44.6%) are male, and the median age is 68 years, 7 (14.89%) patients had middle cerebral artery aneurysm along with A.com.A aneurysm and 1 had internal carotid artery-posterior communicating artery junction aneurysm. Four (8.5%) had chronic subdural hematoma and 1 (2.12%) had epilepsy, 1 (2.12%) case got reoperated, and 1 (2.12%) had hydrocephalus. Moreover, the overall complication rate is 14.89%. For six patients, motor-evoked potential monitoring was used. Forty-six patients had Glasgow outcome scale of 5 and 1 patient had Glasgow outcome scale of 4. There was no mortality in this study. Mean size of the aneurysm was 6.68 mm and the range was 2–25 mm. Mean height was 4.14 mm, 26 (56.52%) A.com.A aneurysm were anteriorly projecting, 9 (19.56%) were superiorly projecting, 8 (17.32%) were inferiorly projecting, and 3 (6.38%) were posteriorly projecting. Morphological parameters such as size, height, and projection were not only highly associated with A.com.A aneurysm rupture and also complications due to clipping of aneurysm.

Endovascular treatment of an unruptured anterior communicating artery aneurysm presenting with acute altitudinal visual field defect: A case report

Purpose

To describe a case of endovascular occlusion of an unruptured anterior communicating artery aneurysm presenting with acute altitudinal visual field defect is presented here.

Methods

A 52-year-old man was evaluated and treated for altitudinal visual field defect in the right eye.

Results

In ophthalmic and neuro-imaging, an accompanying anterior communication artery aneurysm was detected as a cause of visual field defect. He underwent endovascular procedure, yielding excellent outcome as full recovery of visual field defect was observed one month following the procedure and sustained when followed at month 24.

Conclusions

Visual dysfunction is a rare presentation of unruptured anterior communication artery aneurysm. Endovascular procedure may be a safe treatment in these cases.

Isolated abducens nerve palsy associated with subarachnoid hemorrhage: a localizing sign of ruptured posterior inferior cerebellar artery aneurysms

OBJECTIVE Compressive cranial nerve syndromes can be useful bedside clues to the diagnosis of an enlarging intracranial aneurysm and can also guide subsequent evaluation, as with an acute oculomotor nerve (cranial nerve [CN] III) palsy that is presumed to be a posterior communicating artery aneurysm and a surgical emergency until proven otherwise. The CN VI has a short cisternal segment from the pontomedullary sulcus to Dorello's canal, remote from most PICA aneurysms but in the hemodynamic pathway of a rupturing PICA aneurysm that projects toward Dorello's canal. The authors describe a cranial nerve syndrome for posterior inferior cerebellar artery (PICA) aneurysms that associates subarachnoid hemorrhage (SAH) and an isolated abducens nerve (CN VI) palsy. METHODS Clinical and radiological data from 106 surgical patients with PICA aneurysms (66 ruptured and 40 unruptured) were retrospectively reviewed. Data from a group of 174 patients with other aneurysmal SAH (aSAH) were analyzed in a similar manner to control for nonspecific effects of SAH. Univariate statistical analysis compared incidence and risk factors associated with CN VI palsy in subarachnoid hemorrhage. RESULTS Overall, 13 (4.6%) of 280 patients had CN VI palsy at presentation, and all of them had ruptured aneurysms (representing 13 [5.4%] of the 240 cases of ruptured aneurysms). CN VI palsies were observed in 12 patients with ruptured PICA aneurysms (12/66 [18.1%]) and 1 patient with other aSAH (1/174 [0.1%], p < 0.0001). PICA aneurysm location in ruptured aneurysms was an independent predictor for CN VI palsy on multivariate analysis (p = 0.001). PICA aneurysm size was not significantly different in patients with or without CN VI palsy (average size 4.4 mm and 5.2 mm, respectively). Within the PICA aneurysm cohort, modified Fisher grade (p = 0.011) and presence of a thick cisternal SAH (modified Fisher Grades 3 and 4) (p = 0.003) were predictors of CN VI palsy. In all patients with ruptured PICA aneurysms and CN VI palsy, dome projection and presumed direction of rupture were directed toward the ipsilateral and/or contralateral Dorello's canal, in agreement with laterality of the CN palsy. In patients with bilateral CN VI palsies, a medial projection with extensive subarachnoid blood was observed near bilateral canals. CONCLUSIONS This study establishes a localizing connection between an isolated CN VI palsy, SAH, and an underlying ruptured PICA aneurysm. CN VI palsy is an important clinical sign in aSAH and when present on initial clinical presentation may be assumed to be due to ruptured PICA aneurysms until proven otherwise. The deficit may be ipsilateral, contralateral, or bilateral and is determined by the direction of the aneurysm dome projection and extent of subarachnoid bleeding toward Dorello's canal, rather than by direct compression.

Optic neuropathy after anterior communicating artery aneurysm clipping: 3 cases and techniques to address a correctable pitfall

Brain shifts following microsurgical clip ligation of anterior communicating artery (ACoA) aneurysms can lead to mechanical compression of the optic nerve by the clip. Recognition of this condition and early repositioning of clips can lead to reversal of vision loss. The authors identified 3 patients with an afferent pupillary defect following microsurgical clipping of ACoA aneurysms. Different treatment options were used for each patient. All patients underwent reexploration, and the aneurysm clips were repositioned to prevent clip-related compression of the optic nerve. Near-complete restoration of vision was achieved at the last clinic follow-up visit in all 3 patients. Clip ligation of ACoA aneurysms has the potential to cause clip-related compression of the optic nerve. Postoperative visual examination is of utmost importance, and if any changes are discovered, reexploration should be considered as repositioning of the clips may lead to resolution of visual deterioration.

Junctional Chiasmatic Syndrome Due to Large Anterior Communicating Artery Aneurysm

Even though aneurysm involving the anterior communicating artery (A Com A) was common in clinical practice, producing compressive symptoms such as visual loss was rare. We report a case, in which patient had gradually progressive visual loss with features of the junctional chiasmatic syndrome, imaging revealed partially thrombosed large A Com A aneurysm. Intraoperatively, aneurysm was found compressing the optic chiasm and right optic nerve, following clipping and decompression of the optic nerve and chiasm there was gradually improvement in the vision over 2 weeks postoperatively.

Intracranial Aneurysms of Neuro-Ophthalmologic Relevance

BACKGROUND

Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated.

EVIDENCE ACQUISITION

A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review.

RESULTS

Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters.

CONCLUSIONS

Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.

Improved visual acuity after microsurgical clipping of a symptomatic anterior cerebral artery aneurysm: case report

Background: Symptomatic aneurysms of the anterior cerebral artery causing visual impairments are rare and preponderantly lacking in the literature. It is further under discussion, whether operative clipping or endovascular coiling might be superior in order to achieve visual recovery. We therefore present a case of a patient with progressive visual loss caused by an aneurysm of the right A1-A2 segment compressing the ipsilateral optic nerve. Methods: A 57-year-old woman was admitted to our neurosurgical department with visual impairment of the right eye. On admission, visual acuity was 0.05 dpt. and visual field testings showed severe medial and lateral quadrant-anopia. MRI scans and angiography (DSA) demonstrated an aneurysm of the A1-A2 segment compressing the right optic nerve. During surgery, the aneurysm was clipped, the space-occupying dome removed and the nerve relieved from any adhesions. Instantaneously after surgery, visual acuity significantly improved from 0.05 to 0.9 dpt. Conclusions: Anterior cerebral artery aneurysms may present with acute visual impairments and surgical clipping significantly improves impaired visual acuity.

An Unruptured Anterior Communicating Artery Aneurysm Presenting with Left Homonymous Hemianopsia: A Case Report

Unruptured cerebral aneurysms sometimes present with visual symptomsdue to compression of the visual pathways. However, until now, unruptured anterior communicating artery (ACoA) aneurysms presenting visual field defects have been extremely rare. The authors report the case of a 51-year-old woman who presented with left homonymous hemianopsia. Radiological findings demonstrated an ACoA aneurysm filled with thrombus, that was compressing the optic chiasm and post-chiasmal tract. The patient underwent clipping of the aneurysm, which resolved the visual field defect. In cases of visual field defects, an ACoA aneurysm should be included in the differential diagnosis.

High resolution MRI in treatment decision of anterior communicating artery aneurysm accompanied by visual symptoms: Endovascular treatment or surgical clipping? A report of two cases and literature review

Anterior communicating artery (AComA) aneurysm accompanied by visual symptoms is rarely reported. The first case is an asymptomatic 65-year-old woman who presented with an AComA aneurysm, and the pre-procedure high-resolution magnetic resonance imaging (MRI) revealed an AComA aneurysm compressed the left optic nerve and the chiasma with a size of 8.3 × 9.2 mm. She suffered a sudden onset of left eye visual loss and the temporal hemianopia of the right eye after endovascular embolization. She had a light sensation of the left eye and minor enlargement of the visual field in the right eye at the six-month follow-up. The second case is a symptomatic 55-year-old woman suffering a visual loss in the left eye and inferior nasal quadrantanopsia in her right eye. Pre-operative high-resolution MRI found an AComA aneurysm compressing the left part of the chiasma with a size of 7.1 × 8.3 mm. Her visual symptoms improved after surgical clipping. High-resolution MRI could depict the anatomic relationship between the AComA aneurysm and the surrounding optic pathways. Endovascular treatment of an AComA aneurysm may result in visual deterioration due to the mass effect or ischemia after the procedure. Surgical clipping of the AComA aneurysm could relieve the compression symptoms.

The fate of cranial neuropathy after flow diversion for carotid aneurysms

OBJECT

The authors sought to determine whether flow diversion with the Pipeline Embolization Device (PED) can approximate microsurgical decompression in restoring function after cranial neuropathy following carotid artery aneurysms.

METHODS

This multiinstitutional retrospective study involved 45 patients treated with PED across the United States. All patients included presented between November 2009 and October 2013 with cranial neuropathy (cranial nerves [CNs] II, III, IV, and VI) due to intracranial aneurysm. Outcome analysis included clinical and procedural variables at the time of treatment as well as at the latest clinical and radiographic follow-up.

RESULTS

Twenty-six aneurysms (57.8%) were located in the cavernous segment, while 6 (13.3%) were in the clinoid segment, and 13 (28.9%) were in the ophthalmic segment of the internal carotid artery. The average aneurysm size was 18.6 mm (range 4–35 mm), and the average number of flow diverters placed per patient was 1.2. Thirty-eight patients had available information regarding duration of cranial neuropathy prior to treatment. Eleven patients (28.9%) were treated within 1 month of symptom onset, while 27 (71.1%) were treated after 1 month of symptoms. The overall rate of cranial neuropathy improvement for all patients was 66.7%. The CN deficits resolved in 19 patients (42.2%), improved in 11 (24.4%), were unchanged in 14 (31.1%), and worsened in 1 (2.2%). Overtime, the rate of cranial neuropathy improvement was 33.3% (15/45), 68.8% (22/32), and 81.0% (17/21) at less than 6, 6, and 12 months, respectively. At last follow-up, 60% of patients in the isolated CN II group had improvement, while in the CN III, IV, or VI group, 85.7% had improved. Moreover, 100% (11/11) of patients experienced improvement if they were treated within 1 month of symptom onset, whereas 44.4% (12/27) experienced improvement if they treated after 1 month of symptom onset; 70.4% (19/27) of those with partial deficits improved compared with 30% (3/10) of those with complete deficits.

CONCLUSIONS

Cranial neuropathy caused by cerebral aneurysm responds similarly when the aneurysm is treated with the PED compared with open surgery and coil embolization. Lower morbidity and higher occlusion rates obtained with the PED may suggest it as treatment of choice for some of these lesions. Time to treatment is an important consideration regardless of treatment modality.

A Large Ruptured Anterior Communicating Artery Aneurysm Presenting with Bitemporal Hemianopsia

Anterior communicating artery (ACoA) aneurysms sometimes present with visual symptoms when they rupture or directly compress the optic nerve. Giant or large ACoA aneurysms producing bitemporal hemianopsia are extremely rare. Here we present an unusual case of bitemporal hemianopsia caused by a large intracranial aneurysm of the ACoA. A 41-year-old woman was admitted to our neurosurgical department with a sudden-onset bursting headache and visual impairment. On admission, her vision was decreased to finger counting at 30 cm in the left eye and 50 cm in the right eye, and a severe bitemporal hemianopsia was demonstrated on visual field testing. A brain computed tomography scan revealed a subarachnoid hemorrhage at the basal cistern, and conventional cerebral catheter angiography of the left internal carotid artery demonstrated an 18×8 mm dumbbell-shaped aneurysm at the ACoA. Microscopic aneurysmal clipping was performed. An ACoA aneurysm can produce visual field defects by compressing the optic chiasm or nerves. We emphasize that it is important to diagnose an aneurysm through cerebrovascular study to prevent confusing it with pituitary apoplexy.

Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.

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.

Acute Retrobulbar Optic Neuropathy as the Sole Manifestation of Subarachnoid Haemorrhage from a Ruptured Anterior Communicating Artery Aneurysm

Anterior communicating artery aneurysm is the most common form of intracranial aneurysm and subarachnoid haemorrhage (SAH) is the common presenting feature of anterior communicating artery aneurysms. In general, patients with SAH from anterior communicating artery aneurysm present with neurological deficit. We report an interesting case of a 60-year-old man who presented with acute monocular vision loss accompanied by periorbital pain without any neurological deficit, finally diagnosed with SAH from ruptured anterior communicating artery aneurysm. Five months after immediate craniotomy with aneurysm neck clipping, his visual acuity was improved to 20/63 with a pale optic disc appearance. Acute retrobulbar optic neuropathy may be the sole manifestation of SAH from ruptured anterior communicating artery aneurysm. Unilateral decrease of visual acuity with periorbital pain, in the absence of other neurological change, may be the initial and isolated sign.

Influence of surgical or endovascular treatment on visual symptoms caused by intracranial aneurysms: single-center series and systematic review

Object

Intracranial aneurysms of the anterior circulation might become symptomatic by causing visual deficits. The influence of treatment modality on improvement is still unclear. The objective of this study was to analyze the recovery of visual deficits caused by the mass effect of intracranial aneurysms after surgical clipping or endovascular treatment.

Methods

Between June 1999 and December 2009, 20 patients with unruptured intracranial aneurysms causing visual dysfunction due to compression of the optical nerve were treated at the authors' institution. Visual deficits were recorded at admission and at follow-up. To evaluate a larger number of patients, MEDLINE was searched for published studies involving visual disturbance caused by an aneurysm. A multivariate analysis was performed to find independent predictors for favorable visual outcome.

Results

Nine (75%) of 12 patients treated surgically achieved improvement of visual symptoms, compared with 3 (38%) of 8 patients treated endovascularly. A literature review, including the current series, revealed a total of 165 patients with UIAs causing visual dysfunction. Surgical treatment was associated with a significantly higher rate of visual improvement (p = 0.002) compared with endovascular treatment. According to the multivariate analysis, surgical clipping was the only variable significantly associated with improvement of visual outcome (p = 0.02).

Conclusions

Aneurysm-related visual dysfunction developed from direct mechanical compression may improve after surgical clipping and endovascular coiling. However, based on the present series combined with pooled analysis of data from the literature, the only factor significantly associated with improvement of visual dysfunction was surgical clipping.

Anterior communicating artery aneurysm presenting as monocular blindness

Anterior communicating artery (AcomA) aneurysm presenting with rapidly progressing monocular visual loss is rare. We present one such case masquerading as retrobulbar optic neuritis, with no improvement following steroid therapy. Monocular blindness was due to compression of the optic nerve by a large AcomA aneurysm, which was detected after rupture.