Carotid-ophthalmic Artery Research Articles

Intracranial aneurysmal pulsatility as a new individual criterion for rupture risk evaluation: biomechanical and numeric approach (IRRAs Project).

The present study follows an experimental work based on the characterization of the biomechanical behavior of the aneurysmal wall and a numerical study where a significant difference in term of volume variation between ruptured and unruptured aneurysm was observed in a specific case. Our study was designed to highlight by means of numeric simulations the correlation between aneurysm sac pulsatility and the risk of rupture through the mechanical properties of the wall. In accordance with previous work suggesting a correlation between the risk of rupture and the material properties of cerebral aneurysms, 12 fluid-structure interaction computations were performed on 12 "patient-specific" cases, corresponding to typical shapes and locations of cerebral aneurysms. The variations of the aneurysmal volume during the cardiac cycle (ΔV) are compared by using wall material characteristics of either degraded or nondegraded tissues. Aneurysms were located on 6 different arteries: middle cerebral artery (4), anterior cerebral artery (3), internal carotid artery (1), vertebral artery (1), ophthalmic artery (1), and basilar artery (1). Aneurysms presented different shapes (uniform or multilobulated) and diastolic volumes (from 18 to 392 mm3). The pulsatility (ΔV/V) was significantly larger for a soft aneurysmal material (average of 26%) than for a stiff material (average of 4%). The difference between ΔV, for each condition, was statistically significant: P=.005. The difference in aneurysmal pulsatility as highlighted in this work might be a relevant patient-specific predictor of aneurysm risk of rupture.

Progressive visual field defect caused by an unruptured middle cerebral artery aneurysm

Some cerebral aneurysms cause visual dysfunction by comressing the optic pathways, although it is an uncommon symptom. ome previous reports described visual dysfunction caused by cereral aneurysms [1]. The aneurysms most commonly arise from he internal carotid, carotid-ophthalmic or anterior communicatng artery, and the visual symptoms are caused by compression f the anterior visual pathway of optic nerves and optic chiasms. ince the posterior visual pathway including the optic tract and ptic radiation also passes near the cerebral arteries anatomically, his portion could be impaired by cerebral aneurysms. A rare case f visual dysfunction caused by a posterior cerebral artery (PCA) neurysm was reported [2]. However, there is no report of visual isturbance caused by middle cerebral artery (MCA) aneurysm. We report a case of visual dysfunction of the right eye caused y a right MCA aneurysm.

Branch retinal artery occlusion after internal carotid artery angioplasty and stenting.

A 67-year-old man with an embolic branch retinal artery occlusion occurring as a complication of internal carotid artery stenting, despite the use of a distal filter cerebral protection device was reported. Observational case report. One patient case is included in this case report. The patient developed a branch retinal arterial occlusion with visible emboli 24 hours after a carotid angioplasty and stenting procedure and was found to have multiple anastomoses between the external carotid artery and ophthalmic artery as a result of carotid stenosis. He required a second, emergent angioplastic procedure. External carotid-ophthalmic arterial anastomoses can act as a pathway for emboli to travel from the internal carotid artery to the retinal circulation, resulting in retinal arterial occlusions, despite the use of cerebral protective devices. Ophthalmologists and interventional radiologists should be aware of these factors, especially as the number of percutaneous carotid artery stenting procedures continues to increase.

Open and Endovascular Treatment of Unruptured Carotid-Ophthalmic Aneurysms: Clinical and Radiographic Outcomes

Aneurysms of the carotid-ophthalmic artery present unique challenges to cerebrovascular neurosurgeons given their proximity to vital anatomic structures. To report our experience with a combined-modality treatment of unruptured carotid-ophthalmic aneurysms over a 12-year period. A retrospective review of 161 patients who underwent open, endovascular, or combined treatment of 170 aneurysms from January 1997 to July 2009 was conducted. Medical records, operative reports, office notes, and follow-up angiograms were reviewed to obtain data on patient demographics, angiographic results, and clinical outcomes. One hundred forty-seven aneurysms were treated via endovascular techniques; 17 aneurysms (10%) were treated with microsurgical clip ligation; and 6 aneurysms (3.5%) were treated with a combined approach. Of the aneurysms treated via an endovascular approach alone, 81.6% of aneurysms had evidence of ≥ 95% occlusion on initial angiogram. There was a 1.4% rate of major complications associated with the initial procedure. Twenty-six of these aneurysms (18.9%) required further intervention on the basis of early angiographic results. Major complications occurred after 6 of 23 open microsurgical procedures (26.1%), including 2 instances of permanent visual loss. Nine clipped patients had long-term angiographic follow-up; none required further intervention. Endovascular treatment of carotid-ophthalmic aneurysms with modern endovascular techniques can be performed safely and efficaciously in the elective setting.

Balloon test occlusion with hypotensive challenge for main trunk occlusion of internal carotid artery aneurysms and pseudoaneurysms

Background. Balloon test occlusion of carotid artery is a useful procedure in managing patients with internal carotid aneurysms and psuedoaneurysms. Previous studies using intravenous sodium nitroprusside for hypotensive challenge yielded false-negative results for haemodynamic ischaemia, highlighting the difference between pharmacological and compensatory vasodilatory responses. We reviewed our management result of a combined approach of clinical assessment and angiographic assessment of venous drainage using intravenous labetalol for hypotensive challenge.Methods. A retrospective review of all balloon test occlusions carried in a single neurosurgical institute between August 1996 and August 2009 was carried out. Patients with internal carotid artery aneurysms and pseudoaneurysms were reviewed accordingly.Results. The diagnosis at the time of treatment included radiotherapy-induced internal carotid artery pseudoaneurysms in nasopharyngeal carcinoma patients (11/23, 48%), cavernous internal carotid artery giant aneurysm (6/23, 26%) and ophthalmic segment internal carotid artery giant aneurysm (4/23, 17%). Nineteen (79%) patients passed the balloon test occlusion. In the cohort of patients that passed balloon test occlusion and underwent main trunk occlusion, there were no (0/20, 0%) permanent and no (0, 0%) transient neurological complications related to a subsequent parent artery occlusion.Conclusions. A combined approach of clinical assessment and angiographic assessment of venous drainage, using intravenous labetalol for hypotensive challenge, is effective in screening out patients who were at a risk for ischaemia after internal carotid artery occlusion and can serve as a guideline for the selection of patients requiring extracranial–intracranial bypass.

E-054 Endovascular rescue of a misshapen intracranial stent: report of two cases

BackgroundSince FDA approval in May 2007, closed cell intracranial stents have become increasingly used to assist aneurysm coil embolization. Inadvertent deformation and displacement of a deployed closed cell stent may...

Unexpected angiographic and visual findings after clipping of a carotid-ophthalmic aneurysm

A 56-year-old woman underwent surgery for a ruptured carotid-ophthalmic artery aneurysm. Intraoperative visual inspection confirmed that the ophthalmic artery was left intact. She had no light perception on the operated side right after surgery. Angiography one week after surgery confirmed exclusion of the aneurysm, no filling of the proximal portion of the ophthalmic artery, and a very faint filling of its distal orbital part. She gradually recovered from this deficit and 9 months after surgery she is capable of counting fingers. At this time angiography displayed filling of all the portions of the ophthalmic artery, absence of recruitment of collateral blood supply, and exclusion of the aneurysm as before. Surgical manipulation seems to either have induced vasospasm or thrombosis of the ophthalmic artery. Regression of vasospasm or secondary recanalization of the thrombus without development of collateral blood supply may account for the gradual improvement of vision. A risk of monocular blindness is associated with the surgical treatment of para-clinoid aneurysms. Nevertheless, when it occurs, a perspective of recovery may exist if certain etiologies are involved.

Endovascular Treatment of Epistaxis

Epistaxis is a common condition that can be managed conservatively in most cases. When these measures, including anterior and posterior packing of the nasal cavity, are unsuccessful at controlling the bleeding, interruption of the blood supply to the sinonasal area can be performed, either by surgical ligation or by transarterial embolization. Embolization should be preceded by thorough diagnostic angiography. Aside from aiding with subsequent selective catheterization and embolization, such angiography may reveal significant anatomic anomalies, anastomoses, or an unsuspected cause of epistaxis. Taking these findings into account, the interventionalist may decide to refrain from embolization or adjust the technique to minimize the risk of adverse events, which are mostly related to inadvertent embolization of the internal carotid artery or ophthalmic artery. We present a review of the various causes of epistaxis and the treatment options, with emphasis on endovascular embolization. We also describe the protocol of our institution for endovascular management of this condition.

Surgical Treatment of a Post-Traumatic Arteriovenous Fistula of the Superficial Temporal Artery and Vein

Traumatic arteriovenous fistulas (AVFs) are rare, including the scalp, carotid cavernous sinus, vertebral artery and ophthalmic artery. AVF of the scalp is direct connections between the arterial feeding vessels of the scalp and the draining veins without intervening capillary beds. The draining veins are often grossly enlarged and tortuous, like a varix. We experienced a rare case of traumatic AVF involved the superficial temporal artery (STA) and the superficial temporal vein (STV). This report describes successful treatment by clipping at the fistula site and coagulation of draining STV, along with reviews of the related literatures.

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Retinal Embolization and Cerebellar Asymptomatic Embolization after Carotid Stenting Using Distal Balloon Protection

We describe a rare case of having both symptomatic ipsilateral retinal embolization and asymptomatic cerebellar embolization occurring after carotid stenting with use of distal protect device. In this case, external carotid angiograms revealed accessory meningeal arteryophthalmic artery and occipital artery-vertebral artery anastomoses. This case suggested that the protection for external carotid artery should be considered during carotid stenting to avoid retinal embolization and cerebellar or cerebral embolization in cases showing angiographical anastomoses between external carotid artery and ophthalmic artery or intracranial arteries.

Coil Retrieval following Embolization of Cerebral Aneurysms

Failed coil embolization of cerebral aneurysms may be occasionally followed by direct surgical treatment. We had 5 patients who underwent coil retrieval and surgical clipping after coil embolization because of periprocedural complications. The patients, ranging in age from 40 to 71, had wide-neck aneurysms located at the anterior communicating artery (AcomA) in 3 patients, the middle cerebral artery (MCA) in 1, and the internal carotidophthalmic artery (IC-Ophthalmic) in 1. They were embolized with Guglielmi detachable coils (GDCs), which had to be retrieved within 8 days because of coil protrusion and migration in 3 patients, aneurysm rupture in 1, and increased mass effect due to coil compaction in 1. Coils were successfully removed with aneurysmotomy or arteriotomy under temporary trapping, aneurysms were then clipped or trapped. Three patients had a good outcome, but one suffered permanent visual disturbance and the other had a motor deficit. Our study revealed that a small AcomA aneurysm had a high risk of complication in a case of complex anatomy of the AcomA-A1-A2 complex with its difficult access. In addition, insufficient packing of the inflow zone in a large and symptomatic aneurysm may cause coil compaction and regrow with increasing mass effect. The indication and treatment strategy for these aneurysms should be carefully determined.

Early Carotid Endarterectomy after Ischemic Stroke Improves Diffusion/Perfusion Mismatch on Magnetic Resonance Imaging: Report of Two Cases

OBJECTIVE AND IMPORTANCE The functional magnetic resonance imaging techniques of diffusion-weighted imaging and perfusion-weighted imaging allow for ultra-early detection of brain infarction and concomitant identification of blood flow abnormalities in surrounding regions, which may represent brain “at risk.” CLINICAL PRESENTATION We report two patients with acute ischemic stroke associated with ipsilateral high-grade carotid stenosis. The first patient, a 64-year-old woman with a remote history of ischemic stroke and a vertebral artery aneurysm, presented with worsening of her preexisting right hemiparesis. The second patient, another 64-year-old woman with known multiple intracranial aneurysms and bilateral high-grade internal carotid artery stenosis, was admitted for the elective microsurgical clipping of an enlarging giant left carotid-ophthalmic artery aneurysm. Postoperatively, she developed right hemiparesis and mild aphasia. Both patients showed progressive worsening of their neurological deficits in the setting of small or undetected diffusion-weighted imaging abnormalities and large perfusion-weighted imaging defects. INTERVENTION After prompt carotid endarterectomy, symptoms in both patients resolved or improved. Follow-up magnetic resonance imaging scans demonstrated resolution or significant improvement in the perfusion abnormalities in both patients. CONCLUSION Carotid endarterectomy in the setting of diffusion-weighted/perfusion-weighted imaging mismatch can lead to improvement in cerebral perfusion as evidenced by resolution of the perfusion-weighted imaging lesion. Diffusion/perfusion magnetic resonance imaging may be useful in identifying patients with severe neurological deficits but without large territories of infarction who may safely undergo early surgical revascularization.

Two surgical cases of internal carotid–ophthalmic artery aneurysms: Special reference to the usefulness of three-dimensional CT angiography

Three-dimensional computerized tomography angiography (3D-CTA) is a noninvasive tool for the diagnosis of cerebral aneurysms. 3D-CTA is helpful in the evaluation of the configuration of aneurysms and their surrounding vessels and anatomical structures. The aim of this study is to assess the usefulness of 3D-CTA for patients with unruptured internal carotid-ophthalmic artery aneurysms. We pre-operatively obtained surgical simulation images using 3D-CTA and 3D reconstruction and then compared them with magnetic resonance angiography (MRA), conventional cerebral angiography and operative findings in the patients. Two patients with unruptured internal carotid-ophthalmic artery aneurysm were selected. These patients underwent direct neck clipping after the optic canal was unroofed through a combined epidural-subdural approach. The cerebral aneurysm was detected by 3D-CTA, MRA and conventional cerebral angiography in each case. Only by 3D-CTA, however, could we easily detect the relationships among the aneurysm neck, ophthalmic artery and optic canal. Based on this information, direct clipping operations were performed safely without any complications. 3D-CTA is an excellent noninvasive diagnostic method not only for detecting cerebral aneurysms, but also for evaluating the relationships between the aneurysms and surrounding structures.

INTRACRANIAL ANEURYSMS AND AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE: FOLLOWUP STUDY BY MAGNETIC RESONANCE ANGIOGRAPHY

Intracranial aneurysms are known to complicate autosomal dominant polycystic kidney disease. We assess the value of magnetic resonance angiography to detect intracranial aneurysms early in patients with autosomal dominant polycystic kidney disease. We evaluated 15 patients with asymptomatic autosomal dominant polycystic kidney disease treated at our hospital between 1992 and 1998. Magnetic resonance angiography was performed at presentation and was repeated 18 to 72 months after treatment. On the initial magnetic resonance angiogram 3 intracranial aneurysms were detected in 3 patients. The intracranial aneurysms ranged from 4 to 8 mm. in diameter, and were in the anterior communicating artery in 1, in the vertebral artery in 1, and at the bifurcation of the internal carotid artery and ophthalmic artery in 1 case. Repeat magnetic resonance angiography 18 to 72 months after treatment revealed new intracranial aneurysms in 2 patients. In 1 case the lesion was 7 mm. in diameter, in the internal carotid artery and posterior communicating artery, and detected 69 months after the initial angiogram. In the other patient the lesion was 4 mm. in diameter, in the anterior communicating artery and detected 71 months after treatment. Since new intracranial aneurysms were demonstrated in patients followed for a long time periodic repeat magnetic resonance angiography is important.

Preoperative embolization of intracranial meningiomas: a 17-years single center experience.

The purpose of the present report is to review the evolution of endovascular therapy at our center as utilized for the preoperative embolization of intracranial meningiomas over a 17-years period (1982-1998). This study is based upon a consecutive series of 63 patients who underwent preoperative embolization of intracranial meningiomas. Total or subtotal angiographic devascularization of the tumor parenchyma was accomplished in 38 patients (60.3%) who had tumors with either an external carotid artery supply only (n = 30) or with contributions from the cavernous carotid artery, ophthalmic artery, vertebral artery, or pial feeders which were feasible for selective embolization (n = 8). Partial tumor embolizations were attained in the remaining 25 patients (39.7%) because 1. the remanent feeders were considered easily accessible to surgical control in the early stages of dissection, 2. the feeding branches were inaccessible for a microcatheter approach, or 3. superselective microcatheter positions allowing for safe embolization without reflux of embolic material into physiological branches were not achieved. Overall, 97 of 126 tumor feeders identified angiographically were catheterized to selective embolization (77%). Three embolization related complications occurred early in our experience (1982-1989) using techniques which no longer meet standards of treatment. In light of the remarkable evolution of endovascular techniques over the 17-years study period, however, we conclude that preoperative embolization of intracranial meningiomas can be performed safely with the endovascular tools currently available.

内頸動脈-眼動脈分岐部未破裂脳動脈瘤コイル塞栓術後に網膜動脈分枝閉塞症をきたした1例

内頸動脈-眼動脈分岐部未破裂脳動脈瘤コイル塞栓術後に網膜動脈分枝閉塞症をきたした1例

Aneurysmal subarachnoid hemorrhage in Taiwan.

In 1993, the annual report about prospective survey and registry of stroke revealed there were 439 cases of ruptured intracranial aneurysms in Taiwan area. Thirty-two of them had multiple aneurysms; therefore, totally 476 aneurysms occurred in these cases. The anatomic distribution of these aneurysms were as the following: internal carotid artery-posterior communicating artery 32%, anterior communicating artery 30%, middle cerebral artery 18%, carotid bifurcation 6%, anterior cerebral artery 4%, carotid-ophthalmic artery 2%, intracavernous carotid artery 2%, and vertebrobasilar system 6%. 364 cases received surgical or interventional treatment, which 88% was clipping procedure, 8% was interventional procedure with coil, and 4% was wrapping. The surgical mortality was 13%.

内視鏡支援による顕微鏡下脳動脈瘤手術

For the clipping of aneurysmal neck with preservation of main branches or perforators of cerebral arteries, we have used endoscope-assisted technique for 51 aneurysms over the last five years.Aneurysms clipped with the assistance of endoscope include 8 involving the internal carotid-ophthalmic artery, 26 involving the internal carotid-posterior communicating artery (IC-PC) and 11 involving the basilar artery. Thirty-two aneurysms (63.1%) were non-ruptured among them. Four types of rigid endoscope (Olympus and GAAB: angle; diameter, 0; 4mm, 30; 2, 7mm, 70; 4mm, and 110; 4mm, respectively) were applied to observe the arterial branches or perforators before, during, and after neck clipping. Some aneurysms were clipped under the microscope following endoscopic observation, and some were clipped under the microscope during the observation by endoscope, whose head was seated near the aneurysms.Some branches and many perforators that were not identified preoperatively by angiography and intraoperatively by microscope could be preserved under the endoscopic observation. No patients angiographically tested had incomplete clipping. Most patients had an uneventful course, but 1 with IC-PC aneurysm revealed temporary oculomotor palsy. There were initially several problems to be solved: 1) the poorer resolution of picture obtained by endoscope compared with that by microscope; 2) the disturbance of operative handling by using endoscope system; 3) inability of synchronized view between endoscope and microscope. These have been mostly solved. The rigid-type endoscope gives better resolution, electromagnetic-powered point setter makes both hands free from handling of endoscope and a new microscope that has an overlay system has been produced by a company (Olympus, ME 8000).These safer and more satisfactory results indicate that endoscope assisted technique could be applicable not only for the intraventricular surgery as we have discussed but for the clipping of aneurysms.

Preliminary Results on the Management of Unruptured Intracranial Aneurysms with Magnetic Resonance Angiography and Computed Tomographic Angiography

Objective The goal was to assess the capability of magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) to replace catheter angiography in the evaluation of unruptured intracranial aneurysms. Methods A prospective evaluation of a 1-year period included all patients suspected of harboring unruptured intracranial aneurysms at a single institution. All patients underwent magnetic resonance imaging, MRA, and CTA, for comparison with intraoperative findings or results from catheter angiography. Both MRA and CTA now provide submillimeter resolution of vascular structures, with accurate detection of intracranial aneurysms of a diameter greater than or equal to 3 mm. This resolution calls into question the universal need for catheter angiography in the care of patients with suspected intracranial aneurysms. When the catheter angiography can be avoided, radiological costs can be reduced by as much as two-thirds while eliminating the risk of arterial injury and stroke. Results Excellent visualization of the intracranial vasculature was provided by both MRA and CTA. No vascular lesion was detected at surgery or by formal angiography that was not visualized by noninvasive angiographic techniques. The three-dimensional anatomy of the aneurysm complex (unavailable with catheter angiography) was well depicted by both MRA and CTA. CTA was unique in its capacity to display the relationship of vascular structures to bone, information that is invaluable for planning operative strategies for lesions such as carotidophthalmic artery aneurysms. Additionally, acquisition of CTA images was very rapid, with a scanning time of less than 1 minute. Both MRA and CTA allowed for retrospective manipulation of data into an infinite number of views, including views that paralleled those encountered through the operative microscope. Additionally, both MRA and CTA can depict the internal anatomy of aneurysms, an ability not possessed by intra-arterial angiography. This ability alerts the surgeon to possible intraoperative risks, such as plaque in the lumen of an aneurysm or calcium within the walls of the arteries. Conclusion Both MRA and CTA provide several advantages over digital subtraction angiography, in addition to reduced costs and avoidance of arterial injury and stroke. These include retrospective manipulation of data in a 360-degree format, visualization of the internal anatomy of arteries and aneurysms, three-dimensional depiction of anatomy, and rapid data acquisition. Preliminary data and a review of the literature suggest that MRA, when used in concert with CTA, can replace catheter angiography in the assessment of select patients harboring unruptured intracranial aneurysms. Although no firm conclusions or generalizations can be drawn from this small cohort of patients, it is hoped that this report will stimulate interest and further study at other institutions.