The incidence of double aneurysms on the ophthalmic segment of the internal carotid artery (ICA) is very rare. Nevertheless, delayed rupture of a parent artery instead of the aneurysmal sac following the pipeline embolization device (PLED) is unusual.
Ting et al. presented a 72-year-old female who was admitted with a gradual onset of nonspecific visual changes.
Conventional angiography revealed 2 aneurysms located at the ophthalmic segment of the left ICA.
Both aneurysms were successfully treated with PLED.
Two months after discharge, the patient was rushed into the emergency with bilateral conjunctival congestion. Computed tomography revealed intracranial hemorrhage at the left temporal lobe while digital subtraction angiography established a left direct carotid-cavernous fistula. They utilized stent (Solitaire 6*30) assisted coils to occlude the fistula. The patient is well and goes about her normal duties.
Manipulation of the tortuous parent artery resulted in a focal traumatic weakness in the artery and subsequently a delayed tear. Endovascular surgeons should be on the lookout for this complication following flow deviation treatment modalities 1).
A 44-year-old male was admitted with visual decline due to compression of the optic nerve by a large ophthalmic aneurysm. The aneurysm was treated by endovascular coiling, but visual function was unchanged. One month and 7 days later, the patient developed sudden blindness of the affected eye, despite complete angiographical occlusion of the aneurysm. Surgical exploration in an attempt to restore vision showed a fully thrombosed aneurysm but, surprisingly, complete transection of the optic nerve just proximal to its entry into the optic canal.
This report describes a rare complication of a sudden increase in size of a large ophthalmic aneurysm despite successful endovascular occlusion 2).
Microsurgical clipping of large ophthalmic-carotid artery (OA) aneurysms is technically challenging. Among the reported approaches, pterional combined epidural and subdural approach is one of the efficient choices.
Hu et al., applied this approach to treat a 33-year old female patient with a left large OA aneurysm. The step-wise technical details of this approach were reported.
They showed that it is a safe way to clip large OA aneurysms through a step-wise pterional combined epidural and subdural approach, which could make a clear anatomy and a confident manipulation 3).
Peschillo S, Biraschi F, Diana F, Colonnese C, Marenco M, Delfini R. Aneurysms of the Intracranial Segment of the Ophthalmic Artery Trunk: Case Report and Systematic Literature Review. J Neurol Surg A Cent Eur Neurosurg. 2017 Jul 25. doi: 10.1055/s-0037-1604268. [Epub ahead of print] PubMed PMID: 28743134 4).
Hu et al., treated a 33-year old female patient with a left large OA aneurysm. The step-wise technical details of this approach were reported.
They showed that it is a safe way to clip large OA aneurysms through a step-wise pterional combined epidural and subdural approach, which could make a clear anatomy and a confident manipulation 5).
The patient's arteriogram revealed a wide-necked aneurysm of the right ophthalmic artery, an irregular aneurysm of the anterior communicating artery, and a basilar artery aneurysm. The surgical intervention for these aneurysms is a challenge because of the complex anatomical relationship with the surrounding structures. The 3 aneurysms, which were not amenable to a single intervention, were successfully clipped in 1 incision.
After surgery, the patient reported feeling well. One year after surgery, the patient had no SAH recurrence.
Occasionally, surgical treatment was used even for aneurysms of the carotid-ophthalmic artery with aneurysms of anterior communicating artery and basilar artery, which are contraindicated for interventional therapy 6).
Rustemi et al. illustrated the first case of indocyanine green videoangiography (ICG-VA) application in an optic penetrating ophthalmic artery aneurysm treatment. A 57-year-old woman presented with temporal hemianopsia, slight right visual acuity deficit, and new onset of headache. The cerebral angiography detected a right ophthalmic artery aneurysm medially and superiorly projecting. The A1 tract of the ipsilateral anterior cerebral artery was elevated and curved, being suspicious for an under optic aneurysm growth. Surgery was performed. Initially the aneurysm was not visible. ICG-VA permitted the transoptic aneurysm visualization. After optic canal opening, the aneurysm was clipped and transoptic ICG-VA confirmed the aneurysm occlusion. ICG-VA showed also the slight improvement of the optic nerve pial vascularization. Postoperatively, the visual acuity was 10/10 and the hemianopsia did not worsen.
The elevation and curve of the A1 tract in medially and superiorly projecting ophthalmic aneurysms may be an indirect sign of under optic growth, or optic splitting aneurysms. ICG-VA transoptic aneurysm detection and occlusion confirmation reduces the surgical maneuvers on the optic nerve, contributing to function preservation 7).