Right Ophthalmic Aneurysm

Contributor:

Dr. Chris Ekong

Consultants:

Dr. Mike Tymianski
Dr. R Willinsky
Dr. Gary Ferguson

Case 3

Age: 36

Sex: Male

History: Sudden severe headache and blurred vision. Presented three days later after another episode.

Examination

Showed pale right optic disc and tunnel vision. CT of head normal.

Treatment:

Craniotomy and exploration of right Carotid. Large opthalimic aneurysm found on right side compressing on right optic nerve. Haemosiderine found on right optic nerve. Proximal portion of ICA could not be reached . Procedure terminated.

Options:

1. Endovascular treatment

2. Repeat Crani with snare around cervical portion of right ICA.

Comments:

To Neurorounds Group - July 10,2000

I would appreciate your opinion on a current case I performed a craniotomy on three days ago. This 36-year-old man presented with typical history of subarachnoid hemorrhage associated with blurred vision. Angiography did not show any definite aneurysm but his vision was progressively worse and MRI scan showed a right suprasellar mass suggestive of an aneurysm. Apart from tunnel vision he has been alert and neurologically intact. I explored the suprasellar region on the right side and indeed he does have a large ophthalmic aneurysm that has bled. I could not establish a satisfactory proximal control of the internal carotid artery so I abandoned the procedure for now. My initial intention was to proceed at the same time with exposure of the internal carotid in the neck and placement of a snare around it and then carry on with the procedure but as it turned out the CVP line was on that side and a clean dissection of the right carotid would not have been practicable on that sitting. I intend to repeat the procedure in a few days but this time with exposure of the internal carotid in the neck on the right side unless I get a better suggestion including possibility of an interventional procedure. Thank you.

Yours sincerely,

Chris

Dr. Mike Tymianski, Neurosurgeon, Toronto - July 11,2000

Chris:

I looked at the pics with Walter Montanera, who agrees that it's difficult to determine the best treatment when the angio shows the aneurysm doesn't fill well. A repeat angio, now that the Dx of an aneurysm is more certain, might be useful. If it is mostly thrombosed, enthusiasm for endovascular would be lower.

This is a very interesting and unusual case.

I have told Phil Porter and Bob Willinski to check their e-mails about it.

Best,

Mike T

Dr. Robert Willinsky, Neuroradiologist, Toronto - July 11,2000

Dear Chris,

Fascinating case. The discrepancy between the MR findings and angio is interesting. It would suggest that much of the aneurysm is thrombosed. From the OR pictures it looks as though it has a broad base? I think that the aneurysm is either superior hypophyseal (suprasellar variant) or dorsal ophthalmic. It may be one of those "blisters" that have recently been described.

Endovascular tx in not an option. I would recommend a re-exploration with an approach that would allow proximal control. If you feel that it may not be clippable, then a test occlusion with a balloon before the exploration would be prudent.

Best regards,

Bob

Dr. Robert Ferguson, Neuroradiologist, Kingston - July 11,2000

Here is my two cents. The lateral angio shows contrast behind the supraclinoid carotid - definitely not where you would expect with an ophthalmic aneurysm. Furthermore I'm not sure what type of structure the contrast is contained in: i.e. blush vs. intra-aneurysmal.

The MRI T1 images show some high signal (pre-contrast) with little if any enhancement - not what you would expect with an aneurysm unless it was almost completely thrombosed. The vascular "pool" or "blush" is also in the appropriate location for a chiasm lesion such as angioma, schwanoma, meningioma, or even glioma. All of the se lessions could demonstrate a vascular "blush" of the type seen on the lateral angio and might have high signal on T1 images particularly an angioma of the chiasm or a hemorrhagic tumor that might have also ruptured into the subarachnoid space!

What does not fit is the apparent direct visualization of an "aneurysm" at surgery.

Thanks for sharing this difficult case with us. I'd appreciate knowing how this case turns out. Bye.

Patient transferred to Toronto - July 13,2000

Dr. Phillip Porter, Neurosurgeon, Toronto - July 14,2000

Dear Chris,

We repeated his angiogram today. The aneurysm has gone on to thrombose completely. Please find attached the pictures from todays' study. I discussed this with Bob and we feel a long term follow-up angio (eg 6 months - 1yr) would be appropriate. His vision is stable and deficits have been present for about 2 months now, so I don't think optic nerve decompression is indicated.

Very interesting case!

Thanks for involving us even though he cured himself.

Phil

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