Ophthalmic Artery Aneurysm, Right

Contributor:

Dr. Krishna Kumar

Consultants:

Dr. Chris Ekong
Dr. Mike Tymianski
Dr. Gary Ferguson
Dr. Christopher Wallace
Dr. J Max Findlay
Dr. R Willinsky
Dr. Cameron McDougall

Case 10

Age: 68

Sex: Female

History: Sudden severe headaches.

Treatment:

Patient is fully conscious. Has diplopia and neck stiffness. What do we do next?

Comments:

To Neurorounds Group - March 3, 2001

Dear Cameron, Mike, Bob, Walter and Max:

A 68-year-old lady presented a week ago with sudden severe headaches and two seizures. CT scan showed extensive subarachnoid bleed. She is now conscious but occasionally confused. Angiography showed a lesion in the region of the right cavernous sinus and something in the left internal carotid which may be an infundibulum. The CT and angiograms are posted . Your opinion would be appreciated.

Regards,

Chris

Dr. Robert D. G. Ferguson, Neuroradiologist, Kingston - March 5, 2001

I'm not at all convinced that the right sided lesion is intracavernous. I suspect that it is paraopthalmic in origin and as such could easily account for the observed SAH seen on CT. Unfortunately I can't be confident, from these shots, as to the nature of the neck and therefore, if coiling would be effective. Are there any additional views of the right ICA?

If a reasonably defined neck existed, coiling could be attempted. A new device, to permit coiling of larger neck aneurysms, (Tri-Span, Target Therapeutics) has just been approved in Canada. The "balloon remodeling" technique might be attempted as an alternative. I am doubtful that any existing stent technology could be positioned across the neck to form a barrier against coil re-entry. I agree that the left sided lesion is likely an infundibulum. If surgery is attempted but is unsuccessful, it might be possible to treat the remnant with coils. In summary, I would like to know more about the aneurysm neck and hear from the surgeons about the estimate of risks and likelihood of clipping success before offering to attempt coiling.

Bob

Dr. Robert A. Willinsky, Neuroradiologist, Toronto - March 5, 2001

Dear Chris,

I feel that the RICA aneurysm is paraophthalamic and likely is responsible for the bleed. It should be treated. I suspect that the neck is wide but a 3D angiogram would be helpful to assess the neck. I feel that the ideal treatment is surgical using a decompression suction technique with or without drilling the clinoid. As a second alternative, if the neck to sac ratio is reasonable, GDC with balloon remodelling could be done. The tortuosity would make a stent-assisted GDC treatment difficult until we have more flexible stents. A constructive technique with preservation of the parent vessel is critical in the face of SAH. The LICA lesion is likely an infundibulum. This could be confirmed on a follow-up angiogram. I would not treat this lesion.

Thanks for sharing this interesting case.

Best regards,

Bob

Dr. Cameron McDougall, Neurosurgeon, Phoenix - March 5, 2001

Chris:

I think that this is an ophthalmic artery aneurysm and that it would be most reliably treated by clipping. I'm not comfortable calling the other side based on the available images and would work the left side up further.

Cam

Dr. Mike Tymianski, Neurosurgeon, Toronto - March 7, 2001

Chris:

Been Away a couple of days, hence my late reply. I agree with all that this lesion is likely not intracavernous, and likely the one that accounts for the SAH. I'm less concerned about the Lt. sided lesion.

I believe that patients with these types of complex aneurysms benefit from 3D angiography to delineate the lesions better, and help treatment planning. The lesion is likely less amenable to conventional endovascular treatment, and I would recommend that surgery be considered. Without the 3D angio, I still think it likely that it is a broad necked lesion, and will require more than a single clip to reconstruct.

The greatest morbidity associated with treating large aneurysms like this surgically is the loss of the parent vessel. This is dangerous in the face of a Fischer III SAH, as once the patient goes into spasm, the loss of a carotid artery would not be tolerated. For this reason, the surgeon should also be prepared to do an EC-IC bypass in the event that clipping with parent vessel preservation is troublesome (please see Case 1 in your ATLAS SERIES).

My approach would be:

1. 3D angiography for delineation of the neck and size of aneurysm, and to assess cross flow across the a-com, and ipsilateral flow through the p-com (collateral circulation).

2. If endivascular Tx is out, I would recommend direct clipping, with the adjunct of suction decompression as suggested by Bob Willinsky. This will be achievable in most cases like this.

3. In the rare case that clipping is not achievable, or requires sacrifice of the ICA, I would DEFINITELY do a long vein bypass (ECA-MCA M2 branch), lest the patient succumb to vasospasm.

Best,

Michael Tymianski

Dr. Chris Ekong, Neurosurgeon, Regina - March 7, 2001

Dear Mike,

The consensus seems to be that it is the right-sided aneurysm that bled and that it is an ophthalmic aneurysm and that clipping would be the appropriate treatment. The left-sided abnormality still needs further investigation. Patient is being sent to Toronto for 3D angiogram and surgery as indicated.

Thanks for your help, we'll keep you posted.

Chris

Dr. Phillip Porter, Neurosurgeon, Toronto - March 12, 2001

Dear Chris,

Thanks so much for involving us in this interesting and challenging case - definitely one of the most difficult aneurysms I've done in my short career.

The rotational angiogram and 3-D delineated the aneurysm as a wide-necked aneurysm with two lobules and a neck extending proximal to the ophthalmic origin. This was uncoilable. She was operated on via a right pterional craniotomy, exposure of the ICA in the neck for proximal control and suction-decompression, drilling the anterior clinoid and releasing the falciform ligament. At the time of surgery there was a Murphy's teat on the superior lobule, clearly representing the site of hemorrhage. The ICA distal to the aneurysm was fairly easily delineated, but proximally we couldn't get proximal to the neck, even with the ACP fully drilled. At this point we went on trap and used the suction-decompression, hoping to pull the last portion of the neck up into the suction, but it was clearly cavernous. There was a significant drop in the SSEP monitoring just before we came off trap, and this reversed within minutes back to baseline. The suction was very effective in collapsing the aneurysm, which was thin-walled. The aneurysm was clipped (with great difficulty) with a total of 3 clips, leaving only the portion diving proximally, which we wrapped. She awoke without deficit. We'll get a post-op angio in a few days and I'll send those.

Phil

Dr. Phillip Porter, Neurosurgeon, Toronto - March 15, 2001

Hi Chris,

Here are the post-op images, as promised. It shows the expected proximal remnant. I told the family this may grow over time, and could present a risk of recurrent SAH if it did so, or may remodel/thrombose, and that it therefore needs to be followed angiographically.

Phil

Dr. Chris Ekong, Neurosurgeon, Regina - March 15, 2001

Dear Phil,

Good job. Great images. Excellent result images will be posted for others and they will be used in the pocket rounds series.

Thanks

Chris

Progress Report - April 1, 2001

Patient had been awake post op with GCS 13-14. She suddenly became very drowsy today with GCS dropping to 9. Improved to GCS 12 with mannitol. Clinical impression? Vasospasm? Hydrocephalus. Ct shows Hydrocephalus. For VP shunt in a.m.

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