Proper ophthalmic artery aneurysms

Abstract

Background: The ophthalmic segment of the internal carotid artery (ICA) represents a common site for cerebral aneurysms. However, aneurysms of the ophthalmic artery (OphA) itself represent rare lesions and have been associated with trauma and flow-related lesions such as arteriovenous fistulas or malformations. Here, we explore clinical and radiological features of four patients managed for five proper ophthalmic artery aneurysms (POAAs).

Methods: Patients undergoing diagnostic cerebral angiogram (DCA) between January 2018 and November 2021 with newly or previously identified POAA were retrospectively reviewed. Clinical and radiological data were analyzed to identify common and unique features.

Results: Four patients with identification of five POAA were identified. Three patients suffered traumatic brain injury with subsequent identification of POAA on DCA. Patient 1 presented with a traumatic carotid-cavernous-sinus fistula requiring transvenous coil embolization and second stage flow diversion of the ICA. Patient 2 suffered a gunshot wound with ICA compromise, ethmoidal dural arteriovenous fistula (dAVF) development with rapid growth of two POAAs eventually requiring Onyx embolization. Patient 3 was assaulted and DCA showed a POAA without any other cerebrovascular pathology. Patient 4 had undergone N-butyl cyanoacrylate embolization of an ethmoidal dAVF 13 years ago with the feeding OphA carrying a large POAA. Re-DCADCA was performed for a newly developed and unrelated transverse-sigmoid-sinus dAVF.

Conclusion: Management of POAAs poses a challenge to neurovascular surgeons since POAAs inherit a risk for visual deterioration or hemorrhage. DCA facilitates identification of coexisting cerebrovascular pathology. If clinically silent and not accompanied by cerebrovascular disease, observation appears reasonable.

Keywords: Aneurysm; Dural arteriovenous fistula; Ophthalmic artery.

Figure 1:

Patient 1, 55 F, traumatic brain injury. Admission computed tomography-head (a and b). Type A carotid-cavernous fistula in lateral diagnostic cerebral angiogram (DCA)-projection, the retrograde filling of the left superior ophthalmic vein is evident (c). Transvenous coil-embolization was performed in the acute setting (d). Follow-up DCA after 8 months showed a dorsal-medial focal outpouching of the internal carotid artery (ICA) as well as a prominent intracranial proper ophthalmic artery aneurysm (e). Flow diversion using Pipeline embolization device was performed and 6-month follow-up magnetic resonance angiography shows resolution of the ICA defect (f).

Figure 2:

Patient 2, 58 M, right temporal gunshot wound. Admission computed tomography-head (a). A traumatic right-sided ethmoidal dural arteriovenous fistula (dAVF) was evident on lateral diagnostic cerebral angiogram (b). Two minimal outpouchings of the intracranial and intracanalicular segment of the ophthalmic artery were identified as well (c). Three weeks after a complicated course, both proper ophthalmic artery aneurysm (POAAs) grew (d). Treatment of dAVF as well as POAAs was performed through Onyx embolization (e) with successful resolution of the POAAs as well as dAVF (f).

Figure 3:

Patient 3, 31 M, traumatic brain injury. Admission computed tomography-head (a and b). Four-month follow-up diagnostic cerebral angiogram (DCA) for potential vascular compromise was performed revealing a small intracranial proper ophthalmic artery aneurysm (c). Subsequent 4, 9, and 21 months DCA follow-ups demonstrated stable aneurysm size and morphology (d-f, respectively).

Figure 4:

Patient 4 was diagnosed with a left-sided proper ophthalmic artery aneurysm (POAA) (a-c) in a setting of a left (b and c) and right (d) sided ethomoidal dural arterio-venous fistula. After right-sided N-butyl cyanoacrylate (NBCA) embolization, the left side was treated with NBCA as well. However, the ophthalmic artery (OphA) demonstrated contrast stasis in the intraorbital segment – as well as in the POAA – in the postembolization run (e). Follow-up diagnostic cerebral angiogram (DCA) 5 months later revealed reconstitution of a small calibered OphA. However, vision did not recover beyond light-dark perception. Twelve years later, the DCA demonstrated equal findings (f).