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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 957-958

Large internal carotid - ophthalmic artery aneurysm with anterior optic pathway compression


1 Department of Ophthalmology, All India Institute of Medical Sciences, Guntur, Andhra Pradesh, India
2 Department of Radiology, All India Institute of Medical Sciences, Guntur, Andhra Pradesh, India

Date of Submission25-Apr-2022
Date of Acceptance13-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Ganne Pratyusha
Department of Ophthalmology, All India Institute of Medical Sciences, Guntur - 522503, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1035_22

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  Abstract 


Internal carotid-ophthalmic artery aneurysms (IC-OA) are rare lesions that become symptomatic only when they are quite advanced or when complicated by subarachnoid hemorrhage (SAH). We report a case of IC-OA aneurysm in a middle-aged lady who presented with relative afferent pupillary defect, optic disc pallor, significant color vision impairment, and rather preserved visual acuity in the right eye. Magnetic resonance imaging revealed a fuso-saccular aneurysm of the ophthalmic segment causing a pressure effect on the optic nerve. This case emphasizes the importance of careful ocular examination supplemented by neuro-imaging in cases of unexplained visual loss. Early detection can prevent a potentially fatal subarachnoid hemorrhage.

Keywords: Aneurysm, compressive optic neuropathy, internal carotid artery, ophthalmic artery, ophthalmic segment


How to cite this article:
Shyamala DD, Lanka V, Slesser D, Reddy P, Pratyusha G. Large internal carotid - ophthalmic artery aneurysm with anterior optic pathway compression. Indian J Ophthalmol Case Rep 2022;2:957-8

How to cite this URL:
Shyamala DD, Lanka V, Slesser D, Reddy P, Pratyusha G. Large internal carotid - ophthalmic artery aneurysm with anterior optic pathway compression. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:957-8. Available from: https://www.ijoreports.in/text.asp?2022/2/4/957/358142



“Ophthalmic segment,” of the internal carotid artery (ICA) is the longest subarachnoid portion of the ICA, from which there is generally only one named branch, the ophthalmic artery.[1] Aneurysms arising from this segment have been called by various names such as paraclinoid aneurysms, ophthalmic segment aneurysms, and internal carotid-ophthalmic artery (IC-OA) aneurysms. These aneurysms pose a unique challenge to neurosurgeons owing to the complex three-dimensional anatomy of the anterior clinoid process and neurovascular structures around it and also because the diagnosis is often delayed until the aneurysm is large. Here, we describe a case of a large ophthalmic segment aneurysm with anterior optic pathway compression.


  Case Report Top


A 48-year-old lady presented to the ophthalmology clinic with decreasing vision in both eyes for 2 months accompanied by recurrent headaches. She was hypertensive and on medication. She had no ocular complaints in the past. Best-corrected visual acuity (BCVA) was 6/9 in the right eye (RE) and 6/6 in the left eye (LE). Color vision (tested using Ishihara's pseudo-isochromatic plates) was grossly impaired in the RE and preserved in the LE. Extra-ocular movements were full in all directions of gaze in both eyes. A relative afferent pupillary defect (RAPD) was present in the RE and intraocular pressures were normal (16 and 18 mmHg) in both eyes. Fundus examination revealed temporal pallor of the optic disc and a cup-disc ratio of 0.6:1in the RE [Figure 1]a. Fundus examination of the LE was normal [Figure 1]b. Static visual field testing (30-2) showed a generalized reduction of sensitivity, focal depressed points in superior and inferior visual fields in the RE, and a normal visual field in the LE [Figure 2]a and [Figure 2]b. Optical coherence tomography (OCT) showed peripapillary retinal nerve fiber layer (RNFL) thinning (temporal and superior quadrants) in the RE.
Figure 1: Color fundus photographs of the right (a) and left (b) eyes showing disc pallor in the right eye

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Figure 2: (a and b): Static visual field testing (30-2) of the right and left eyes showed a generalized reduction of sensitivity, focal depressed points in superior and inferior visual fields, and spared central vision in the RE and a normal visual field in the LE

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Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain and orbits showed a large fuso-saccular aneurysm (9 mm × 9 mm × 16 mm) arising from the ophthalmic segment of the right ICA compressing the cisternal segment of the right optic nerve (ON) [arrow, [Figure 3]a and [Figure 3]b]. The patient underwent microsurgical clipping of the aneurysm.
Figure 3: (a): T2-weighted fat-saturated axial sections of both orbits showing a bulbous flow void (right arrow) from the ophthalmic segment aneurysm compressing the anterior part of the cisternal segment of the right optic nerve. (b) MR angiography image (right postero-lateral projection) showing a fuso-saccular aneurysm (9 mm × 9 mm × 16 mm) (left arrow) from the ophthalmic segment of the ICA

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  Discussion Top


IC-OA aneurysms account for 5% of all intracranial aneurysms.[2] They have been reported to be commoner in females and are associated with other aneurysms in approximately 20% of cases.[3] Frequently, it is the visual symptoms that prompt medical attention rather than subarachnoid hemorrhage (SAH) in these patients. The visual symptoms can range from a decrease in central visual acuity to visual field defects and color vision deficits and can rarely present with external ophthalmoplegia.[4],[5],[6],[7],[8],[9] Visual field defects reported in patients with IC-OA aneurysms include bitemporal hemianopsia, central scotoma, nasal quadrantanopia, and temporal hemianopsia.[4],[7] Non-ocular manifestations include headache, dizziness, facial pain, epistaxis, and more serious stroke and SAH.[4],[5],[6],[7],[8],[9]

Surgical management of these aneurysms is technically challenging owing to the complex anatomy of this region and the large size of these aneurysms at diagnosis. Micro-surgical clipping, endovascular approach, or a combination has been tried for treating these aneurysms.[5],[6],[7],[8],[9] The outcomes of these surgical procedures have improved with advances in cranial base approaches and surgical techniques. Visual symptoms improve in a significant proportion of these patients following surgery. However, a small sub-group of patients (3%) can develop new visual deficits.[6] Post clipping, visual deficits can occur due to direct vascular compromise of the optic nerve, excessive manipulation, direct heat from the high-speed drill damaging the optic nerve, or post-surgical inflammation. Vision loss post-coiling may result from emboli to the optic nerve or retina, an increase in mass effect from coil packing, or coil-related peri-aneurysmal inflammation.[6],[7],[8] Recent advent of endovascular flow diversion procedures has mitigated the risk of post-intervention visual loss while maintaining aneurysm occlusion rates similar to coiling.[10]

In the current case, the visual acuity was relatively well preserved, and visual field analysis did not reveal significant defects. However, the other findings such as the presence of RAPD, disc pallor, color vision deficits, and RNFL thinning prompted us to get magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain and orbits. It is important to carefully evaluate hypertensive patients with unexplained headaches and visual disturbances for this uncommon entity.


  Conclusion Top


Ophthalmologists should carefully look for subtle signs of optic nerve dysfunction such as RAPD, color vision deficits, and optic nerve head pallor in cases presenting with unexplained gradual unilateral or bilateral vision loss. The presence of any of these signs mandates further testing with visual field charting and peripapillary RNFL thickness measurement on OCT. Contrast-enhanced MRI with thin sections along with MRA will help diagnose such aneurysms in the early stage and improve surgical and visual outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors report no conflicts of interests nor have any financial disclosures to make related to this submission.



 
  References Top

1.
Gibo H, Lenkey C, Rhoton AL Jr. Microsurgical anatomy of the supraclinoid portion of the internal carotid artery. J Neurosurg 1981;55:560-74.  Back to cited text no. 1
    
2.
Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations: Based on 6368 cases in the cooperative study. J Neurosurg 1966;25:219-39.  Back to cited text no. 2
    
3.
Kachhara R, Nair S, Nigam P. Ophthalmic segment aneurysms: Surgical treatment and outcomes. J Neurosci Rural Pract 2021;12:635-41.  Back to cited text no. 3
    
4.
Date I, Asari S, Ohmoto T. Cerebral aneurysms causing visual symptoms: Their features and surgical outcome. Clin Neurol Neurosurg 1998;100:259-67.  Back to cited text no. 4
    
5.
Heran NS, Song JK, Kupersmith MJ, Niimi Y, Namba K, Langer DJ, et al. Large ophthalmic segment aneurysms with anterior optic pathway compression: Assessment of anatomical and visual outcomes after endosaccular coil therapy. J Neurosurg 2007;106:968-75.  Back to cited text no. 5
    
6.
Hoh BL, Carter BS, Budzik RF, Putman CM, Ogilvy CS. Results after surgical and endovascular treatment of paraclinoid aneurysms by a combined neurovascular team. Neurosurgery 2001;48:78-89.  Back to cited text no. 6
    
7.
Mattingly T, Kole MK, Nicolle D, Boulton M, Pelz D, Lownie SP, et al. Visual outcomes for surgical treatment of large and giant carotid ophthalmic segment aneurysms: A case series utilizing retrograde suction decompression (the “Dallas technique”). J Neurosurg 2013;118:937-46.  Back to cited text no. 7
    
8.
Schuss P, Guresir E, Berkefeld J, Seifert V, Vatter H. Influence of surgical or endovascular treatment on visual symptoms caused by intracranial aneurysms: Single-center series and systematic review. J Neurosurg 2011;115:694-99.  Back to cited text no. 8
    
9.
Nanda A, Javalkar V. Microneurosurgical management of ophthalmic segment of the internal carotid artery aneurysms: Single-surgeon operative experience from Louisiana State University, Shreveport. Neurosurgery 2011;68:355-70.  Back to cited text no. 9
    
10.
Burrows AM, Brinjikji W, Puffer RC, Cloft H, Kallmas DF, Lanzino G. Flow diversion for ophthalmic artery aneurysms. AJNR Am J Neuroradiol 2016;37:1866-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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