Ophthalmic Artery Aneurysm Research Articles

Treatment of Acute Iatrogenic Cerebrovascular Injury Using Flow Diverter Stents

BACKGROUND AND OBJECTIVES: Iatrogenic cerebrovascular injury can cause intracranial hemorrhage and pseudoaneurysm formation, putting patients at high risk for postoperative bleeding. No consensus for management exists. This study describes endovascular treatment of these acute injuries with flow diverter stents. METHODS: Electronic medical records were retrospectively reviewed for injury type and etiology, timing of diagnosis, and endovascular management, including antiplatelet regimens, embolization results, and clinical outcome. RESULTS: Six patients were included. Three suffered an injury to the internal carotid artery, 1 suffered an injury to the left anterior cerebral artery, 1 suffered an injury to the right posterior cerebral artery, and 1 suffered an injury to the basilar artery. Four of the 6 injuries occurred during attempted tumor resection, 1 occurred during cerebrospinal fluid leak repair, and 1 occurred during an ophthalmic artery aneurysm clipping. All injuries resulted in pseudoaneurysm formation. Four were immediately detected on angiography; 2 were initially negative on imaging. Five were treated with a pipeline embolization device, and 1 was treated with a Silk Vista Baby. Two were treated with 2 pipeline embolization devices telescopically overlapped across the pseudoaneurysm. All devices deployed successfully. No pseudoaneurysm recurrence or rebleeding occurred. No parent artery occlusion or stenosis was observed, and complete pseudoaneurysm occlusion was observed in 4 patients (in 2 patients, follow-up imaging could not be obtained). CONCLUSION: With proper antiplatelet regimens, flow diverter stents can be used safely to successfully treat complex acute iatrogenic injuries. Early repeat angiogram is needed when immediate postinjury imaging does not discover the point of vessel injury.

Contralateral approach to giant ruptured and unruptured ophthalmic artery aneurysms: patient series.

Giant ophthalmic artery (OphA) aneurysms remain surgically challenging despite the progress in endovascular treatments. This study describes the contralateral interoptic corridor in select patients based on imaging criteria suitable for clipping. The aim of this study was to show that despite the growing use of novel endovascular techniques, such as coil embolization and flow diversion, for the treatment of OphA aneurysms, microsurgical clipping may still be preferred for giant ones under certain conditions. The authors retrospectively reviewed the records of the microsurgical treatment of unruptured and ruptured giant OphA aneurysms at the University Hospital Center "Mother Teresa," Tirana, from 2007 to 2016. Four patients were selected for microsurgery and the contralateral approach using ophthalmic evaluations and coronal imaging on computed tomography, magnetic resonance imaging, and digital subtraction angiography that demonstrated aneurysms with a small neck and an orientation between 11 and 13 on the coronal clock face. A prefixed chiasm was a contraindication to this approach. Giant OphA aneurysms can be safely clipped through a contralateral interoptic corridor without creating new visual deficits or a residual aneurysm. https://thejns.org/doi/10.3171/CASE2473.

Microsurgical treatment of ophthalmic artery aneurysm, a case series of 55 patients with long-term follow-up

BackgroundOphthalmic artery aneurysm (OAA) can be secured in endovascular or microsurgical approaches. Still there are controversies in technique selection and their long term outcomes.MethodsAll the patients with OAA were treated microsurgically and followed. Demographic data, neurological status, physical examination findings, angiographic data, operation details, and intraoperative and postoperative events were recorded and analyzed. P < 0.05 was considered significant.ResultsAmong 55 patients, 38 were females (69.1%). Median preoperative glasgow coma scale (GCS), Fisher Grade, and Hunt and Hess(HH) scores were 15, 1 and 1, respectively. The most common neurologic manifestation was visual problems (n = 15). The most common anatomical projection was medial (43.6%) oriented lesions. 85.5% of them only had 1 ophthalmic aneurysm while multiple aneurysms were reported in 14.6%. In 52 patients temporary clip was used. in 21 patients (38.2%) intraoperative aneurysm rupture occurred. Larger aneurysm size and preoperative hydrocephalus were associated with higher rates of aneurysm rupture (P = 0.003 and 0.031). 28.5% of the patients with visual problems had clinical improvement in the postoperative period. The mean follow-up period was 5 years. Follow-up angiography showed a 100% obliteration rate with a 0.0% recurrence rate. Median values for follow-up glasgow outcome scale and modified Rankin scale were 5 and 0, respectively. favorable neurological outcomes were associated with better primary GCS and HH scores.ConclusionOAA microsurgery is an effective and safe procedure with significant improvement in both visual and neurological status. Low recurrence rate and excellent clinical recovery are the most important advantages of microsurgery in OAA treatment.

Abstract 101: Ophthalmic Artery Aneurysm Embolization Resulting in Resolution of Headaches and Visual Symptoms

Introduction Cerebral aneurysms are a rare cause of headaches and visual symptoms. Most common locations include anterior communicating artery, internal carotid arteries (ICAs), middle cerebral arteries, and tip of the basilar artery. While most unruptured aneurysms are asymptomatic, when symptoms do occur, they are most often headaches, cranial nerve palsies, or bilateral temporal hemianopsia due to compression of surrounding nerves or the optic chiasm. Rarely, thrombus formation within an aneurysm can lead to symptoms via distal embolization and infarction. The literature is limited regarding repeated aneurysmal microembolism formation or transient alterations in blood flow dynamics leading to episodic symptoms. Methods We report the case of a 55 year‐old woman with Ehlers‐Danlos syndrome and syringomyelia who presented to the hospital with one week of intermittent left eye visual disturbances, characterized by either complete transient monocular vision loss or blurriness lasting for 30 seconds at a time and occurring multiple times per day. These symptoms were also associated with pressure‐like headaches that originated around the left eye and radiated to the left side of her head. Results Neurological and ophthalmological examinations were notable for normal cranial nerve function, including intact visual acuity, visual fields, color vision and extraocular movements in each eye. On a dilated fundoscopic exam, there were no retinal or optic disc abnormalities. The rest of the neurological exam was normal. Head and neck CTA and subsequent digital subtraction angiography (DSA) showed multiple bilateral ICA aneurysms, as well as a 4 millimeter left ophthalmic artery aneurysm. Brain and orbits MRI with contrast showed no acute abnormalities, including no evidence of infarction or intracranial hemorrhage. She was started on clopidogrel due to concern for recurrent retinal transient ischemic attacks as well as escalating doses of nortriptyline for empiric treatment of possible ocular migraines. In follow‐up three months later, she continued to have the same visual and headaches symptoms. She underwent a successful elective flow diversion embolization of the ophthalmic artery aneurysm with subsequent resolution of her symptoms Conclusion Here we describe a case of a patient who presented with episodic monocular vision changes and headaches ipsilateral to an ophthalmic artery aneurysm, who experienced complete resolution of these symptoms following flow diversion embolization of the aneurysm. Although the precise pathophysiological relationship between the aneurysm and her visual symptoms is unclear, potential mechanisms include aneurysmal microthrombus formation with retinal embolization and dissolution, hemodynamic retinal blood flow changes related to the aneurysm, or recurrent ocular migraines triggered by the ophthalmic artery aneurysm.

Clipping of Bilateral Ophthalmic Artery Aneurysms Through a Single Craniotomy.

Bilateral ophthalmic aneurysms are rare and involve two aneurysms in the ophthalmic arteries, one on each, leading to potential symptoms such as vision loss and headaches. The treatment options for aneurysms, ranging from surgery and endovascular embolization to observation, depend on various factors, including aneurysm size and the patient's health.Microsurgery, while presenting complexities due to the intricate anatomy of the anterior clinoid region, offers potential advantages such as enhanced decompression rates and reduced aneurysm recurrence. The presented surgical video illustrates the treatment of bilateral ophthalmic artery aneurysms via a single craniotomy. This method reduces surgical duration and trauma, facilitating quicker patient recovery. However, this method bears potential risks, especially to both optic nerves. As underscored in the video, the utmost anatomical understanding in the anterior clinoid area is pivotal for successful outcomes and reduced complications.

Proper ophthalmic artery aneurysms.

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). 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. 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. 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.

A boxer with a pipeline stent in the brain- Should this boxer be allowed to participate in professional boxing fight?

Professional boxing is a popular combat sport which unfortunately carries a high risk of acute traumatic brain injury (TBI). The nature of the sport is such that every punch thrown to the opponent’s head is thrown with the intention of winning by causing a concussive head injury (aka a knockout). Professional boxing is regulated by various State Athletic Commissions in the United States and abroad. Most commissions require an imaging study of the brain (either a computed tomography scan or a magnetic resonance scan) prior to licensure. The primary goal of neuroimaging prior to licensure is to identify and/or exclude coincidental or clinically suspected brain lesions which may pose a risk for rupture, bleeding, or other catastrophic brain injury during a bout/training. These lesions include aneurysms, arteriovenous malformations, cavernous malformations, large venous malformations, Vein of Galan malformations among others. A boxer with history of a left ophthalmic artery aneurysm status post embolization with placement of a pipeline shield in the distal left internal carotid artery (ICA) presented for licensure. Should this boxer be allowed to participate in professional boxing is debated.

Abstract Number ‐ 136: Aspirin Desensitization in Cerebral Aneurysms and Management for the Neurointerventionalist

Introduction Aspirin (ASA) is the pillar of cerebrovascular and systemic vascular disease management. ASA allergy/hypersensitivity presents a challenge to the NeuroInterventionalist due to difficulties achieving optimum medical management prior to and after neurointerventional treatment. Currently there is vast cardiovascular literature describing successful ASA desensitization protocols, however the same cannot be said for neurointervention.The purpose of our study was to describe our experience with ASA hypersensitivity management in cerebrovascular disease and review of the relevant literature in patients with aneurysms. We present two cases of patients with cerebrovascular aneurysms requiring neurointervention with a pipeline embolization device who were successfully desensitized to their ASA hypersensitivity prior to treatment and the different variables encountered/approach for each patient. Methods N/A Results 37 yo F with history of pre‐eclampsia while pregnant with twins presented with complaints of a severe headache 22 days after delivery and on MRA head and neck had unruptured bilateral paraclinoid para‐ophthalmic internal carotid artery aneurysms. She was placed on Brilinta instead of Plavix due to subtherapeutic PruTest. She underwent successful endovascular coil embolization of the unruptured RIGHT paraclinoid para‐ophthalmic internal carotid artery aneurysm. Post coil embolization she underwent desensitization in the ICU for ASA under the care of the ICU physician and the allergist; 1mg, 5mg, 10mg, 20mg, 45mg ‐ each given 30 min apart. The protocol was followed by ASA 81mg the next morning and had successful endovascular flow diversion with Pipeline Flex Embolization Device for LEFT paraclinoid para‐ophthalmic internal carotid artery aneurysm. 71 yo F with history of uncontrolled HTN. During her hypertensive work‐up was found to have an approximately 6 mm unruptured right internal carotid artery aneurysm on CTA. She was successfully desensitized to ASA and optimized with Aspirin and Brilinta. She underwent successful endovascular flow diversion with Microvention FRED X Flow Diverter of the unruptured medially directed right paraclinoid ophthalmic segment internal carotid artery aneurysm. Conclusions There are few reports of ASA desensitization in patients with cerebral aneurysms ‐ due to this there are few established set protocols. We describe our protocol for high risk patients and post‐op management of patients undergoing neurointerventional procedures.We report these 2 case reports to help add to the current literature of ASA desensitization utilization in patients with CNS aneurysms and may help create more standardized protocols.

Elongated, finger-like ophthalmic segment aneurysms: Implications for selection of treatment modality

BackgroundMicrosurgical treatment of ophthalmic segment aneurysms often requires anterior clinoidectomy and optic nerve mobilization prior to successful clipping. ObjectiveWe hypothesize that ophthalmic segment aneurysms that are elongated and finger-like grow unconstrained, lateral to the optic nerve. We note that this avoids the need for clinoid resection and optic nerve mobilization. MethodsThree cases with up-pointing aneurysms were reviewed. Patient and aneurysm characteristics were collected. ResultsThe first two patients with elongated ophthalmic segment aneurysms were found to have aneurysms growing lateral to the optic nerve. This allowed for straightforward treatment via microsurgical clipping without anterior clinoidectomy or division of the falciform ligament. The third patient presented with distortion of the optic chiasm superiorly and medially by a giant ventral ICA aneurysm. A concomitant ophthalmic aneurysm in this patient exhibited elongated morphology, with a high-resolution MRI demonstrating the patient’s optic nerve was located inferior and medial to the ophthalmic artery aneurysm dome. This supports our hypothesis that an overriding optic nerve normally impedes vertical growth of ophthalmic segment aneurysms. ConclusionsOphthalmic segment aneurysms may acquire a round morphology when their growth is constrained superiorly by the optic nerve. Elongated ophthalmic segment aneurysms may be the result of growth lateral to the optic nerve. For these aneurysms, an anterior clinoidectomy is not required, and microsurgical clipping represents a straightforward treatment option.

Cerebral Aneurysm Imaging at 7 T with Use of Compressed Sensing.

HomeRadiologyVol. 306, No. 3 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyCerebral Aneurysm Imaging at 7 T with Use of Compressed SensingAmit Desai, Erik H. Middlebrooks Amit Desai, Erik H. Middlebrooks Author AffiliationsFrom the Department of Radiology, Mayo Clinic College of Medicine and Science, 4500 San Pablo Rd, Jacksonville, FL 32224.Address correspondence to E.H.M. (email: [email protected]).Amit DesaiErik H. Middlebrooks Published Online:Oct 18 2022https://doi.org/10.1148/radiol.221277MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Online supplemental material is available for this articleA 51-year-old woman was diagnosed with hypertension and found to have stage IV chronic kidney disease (estimated glomerular filtration rate = 24). Her family history was significant for a father with end-stage renal disease and dialysis starting at age 54 years. She was subsequently diagnosed with autosomal dominant polycystic kidney disease. Screening for intracranial aneurysms with intracranial time-of-flight (TOF) MR angiogram (MRA) (Figure) showed a superiorly projecting left ophthalmic artery aneurysm measuring 4 mm from neck to dome (Figure).Images in a 51-year-old woman with autosomal dominant polycystic kidney disease undergoing screening for intracranial aneurysm. Images are (A) cinematic rendering of 1.5-T time-of-flight (TOF) MR angiogram (MRA) versus (B) 7-T TOF MRA. The 7-T MRA better illustrates the complexity of the aneurysm sac, as well as the relationship to the ophthalmic artery origin (arrow).Download as PowerPointOpen in Image Viewer To better characterize the aneurysm, ultra-high resolution TOF MRA was repeated with a 7-T Siemens Terra MRI (Siemens Healthineers) with use of a 32-channel receive and eight-channel transmit head coil (Nova Medical) (Figure, Movie [online], Figure S1 [online]). Relevant imaging parameters include: repetition time of 51 msec, echo time of 5.61 msec, section thickness of 0.3 mm, flip angle of 20°, field of view of 220 × 174 mm, matrix of 704 × 552, and voxel size of 0.3 × 0.3 × 0.3 mm. Image acceleration was performed with compressed sensing with an acceleration factor of 7.2, resulting in an acquisition time of 8 minutes 16 seconds. The combination of ultra-high field strength scanner and compressed sensing allows for a voxel more than 90% smaller than standard clinical TOF MRA at 1.5 T (1).Get the Flash Player to see this video.Movie: Rotational video of cinematic rendered 7T time-of-flight MR angiogram.Download Original Video (2.2 MB)MRA is highly advantageous at 7 T due to the longer T1 relaxation time and increases in the signal-to-noise and contrast-to-noise ratios. The benefits of 7-T MRA have been shown previously, such as an alteration of diagnosis in 66% of cases scanned at 7 T versus 3 T (2). In this case, we have shown the utility of compressed sensing acceleration in 7-T TOF MRA, allowing a nearly 50% reduction in voxel volume over such previously published 7-T MRA cases (2).Disclosures of conflicts of interest: A.D. No relevant relationships. E.H.M. Grants or contracts from clinical trial sponsor by Varian Medical Systems; consultant for unrelated work from Varian Medical Systems and Boston Scientific; paid honorarium for educational lectures from Varian Medical Systems.

Partial medial clinoidectomy with optic canal roof drilling for clipping of ophthalmic artery aneurysms: how I do it.

Clipping of ophthalmic artery (OA) aneurysms present one of the treatment strategies for long-term disease management. Existing surgical techniques primarily require extra/intradural removal of the anterior clinoid process, carrying a higher risk of infection, damage to surrounding structures or technical complications. We present the technique of minimally invasive partial medial clinoidectomy with the unroofing of the optic canal for surgical clipping of OA aneurysms, and besides its pros and cons, we also discuss proper technical indications. The partial medial clinoidectomy improves manoeuvrability around the paraclinoid region, provides better protection for adjacent structures and renders excellent treatment outcome.

Intraoperative Angiogram Using C-Arm Fluoroscopy and Direct Common Carotid Artery Puncture During Surgical Treatment of Paraclinoid Aneurysms

Intraoperative angiography (IOA) has been shown to be a useful adjunct in surgical treatment of cerebral aneurysms. However, its use can be limited by hybrid operating room availability. On the other hand, the use of C-arm fluoroscopy can add challenges to IOA during navigation of the aortic arch and selection of the great vessels. We aimed to describe a simple method of IOA that can be applied during surgery of paraclinoid aneurysms and can be performed in a normal operating room without the need to navigate the aortic arch. In patients undergoing surgery for paraclinoid aneurysms with need for cervical carotid artery exposure, IOA was performed using a single plane C-arm fluoroscopy unit after direct puncture of the carotid artery. Five patients were included: 2 with subarachnoid hemorrhage, 2 with unruptured aneurysm and history of subarachnoid hemorrhage, and 1 with unruptured aneurysm. There were 2 internal carotid blister aneurysms, 2 ophthalmic artery aneurysms, and 1 superior hypophyseal artery aneurysm. IOA was performed using direct carotid puncture through the neck incision required for proximal control. In all cases, intraoperative images were of sufficient quality to determine the completeness of aneurysm occlusion as well as parent and branching vessel patency. There were no postoperative infarctions and no complications related to IOA. IOA using direct carotid puncture can be performed in a standard operating room with the use of a C-arm, eliminating the need to catheterize the great vessels of the aortic arch.

Incomplete occlusion and visual symptoms of peri-ophthalmic aneurysm after treatment with a pipeline embolization device: a multi-center cohort study.

Peri-ophthalmic aneurysm is a special type of aneurysm. We assessed the relationship between ophthalmic artery (OA) origin and aneurysm and examined the effect of a pipeline embolization device (PED, Covidien/Medtronic) with or without coils on aneurysm occlusion rate and visual outcomes. We retrospectively analyzed 194 peri-ophthalmic aneurysms in 189 patients among 1171 patients treated with a PED in a Chinese post-market multi-center registry study from November 2014 to October 2019. Peri-ophthalmic aneurysms were defined as carotid-ophthalmic segment aneurysms arising from the internal carotid artery dorsal wall at, or distal to, the OA origin, with a superior or superomedial projection. The relationship between OA origin and the aneurysm was classified as follows: type A, OA originating separate from the aneurysm; type B, OA originating from the aneurysm neck or dome. Patients with aneurysm were divided into the PED-only group and the PED + coils group according to treatment. The median follow-up time was 6.8months (range, 5.3-20.2months). There were 163 occluded aneurysms (84%) and 31 aneurysms with incomplete occlusion (16%). A multivariate analysis showed that type B aneurysm was a risk factor for incomplete occlusion in the PED-only group (odds ratio [OR] 4.854, 95% confidence interval [CI] 1.878-12.548, P = 0.001). Visual symptoms at final follow-up correlated with preoperative visual symptoms (OR 22.777, 95% CI 3.115-166.555, P = 0.002). Type B aneurysm is associated with a lower occlusion rate after PED-only treatment. Patients with preoperative visual symptoms should be treated promptly to avoid permanent visual symptoms.

A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms.

Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings. The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications. A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications. Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

Comparison of Visual Outcomes of Ophthalmic Artery Aneurysms Treated with Microsurgical Clipping and Endovascular Coiling.

PurposePost-treatment visual deficit is a major concern associated with both microsurgical clipping and endovascular coiling for the treatment of ophthalmic artery (OphA) aneurysms of the internal carotid artery. We aimed to compare the safety and effectiveness of the 2 modalities.Materials and MethodsWe retrospectively reviewed and compared the baseline characteristics and postoperative visual and angiographic outcomes of OphA aneurysms treated by clipping or coiling between January 2010 and August 2018 at our hospital. In addition, the balloon occlusion test was performed to evaluate the safety of OphA occlusion.ResultsThis study included 56 aneurysms treated by clipping and 82 aneurysms treated by coiling. Both the immediate and follow-up rates of incomplete aneurysm occlusion were comparable between the 2 groups (21.4% vs. 22.0%; 24.4% vs. 23.6%). The incidence of post-treatment visual deficits was higher in the clipping group than in the coiling group (16.1% vs. 2.4%; P=0.010). We observed total ipsilateral OphA occlusion in 6 patients and near occlusion in 3 patients during endovascular coiling; however, only 1 patient with near OphA occlusion showed a post-treatment visual field defect.ConclusionOphA aneurysms treated by endovascular coiling exhibited an aneurysm occlusion rate similar to that of microsurgical clipping with fewer post-treatment visual deficits. The total occlusion of OphA with adequate collaterals did not cause post-treatment visual deficits.

Letter to the Editor: Commentary on Coil Embolization of Traumatic Ophthalmic Artery Aneurysm: Case Report (Korean J Neurotrauma 2022;18:98-102).

Letter to the Editor: Commentary on Coil Embolization of Traumatic Ophthalmic Artery Aneurysm: Case Report (Korean J Neurotrauma 2022;18:98-102).

Abstract 13783: Predictors and Prognostic Implications of Stress Cardiomyopathy in Aneurysmal Sub-Arachnoid Hemorrhage: Findings From a 14-year Prospective Registry

Objective: Stress cardiomyopathy(SCM) occurs between 4-15% in aneurysmal sub-arachnoid hemorrhage(aSAH). Predictors and prognostic implications of SCM in aSAH remains incompletely known. Methods: Adult patients between January 2006-December 2019 with diagnosis of aSAH and echocardiogram during same admission were identified from a prospectively maintained aSAH registry. Presence of SCM was confirmed using the echocardiographic criteria. Severity of aSAH was categorized using the modified Fisher(mFisher) and the World Federation of Neurological Scale(WFNS). Results: Among 570 aSAH patients during study period, 194 aSAH cases had echocardiography and 37(19%) of them had SCM. In comparison to aSAH without SCM, aSAH with SCM were mainly females(76% vs 62%; p= 0.12) and postmenopausal(57±12 vs 59±13 years; p= 0.39). Echocardiographic findings in Table . aSAH with SCM was associated with WFNS grade&gt;3(68% vs 42%; p= 0.005) and mFisher grade&gt;2(87% vs 81%; p= 0.39), intraventricular hemorrhage(IVH)(81% vs 64%; p= 0.04) and larger size of the ruptured aneurysm(8±5 vs 6±4; p= 0.04). Medical management, microsurgical clipping and endovascular coil embolization rates were similar in patients with and without SCM, yet patients with SCM had lower rates of disposition to home(8% vs 27%; p =0.02) and higher in-hospital mortality(41% vs 25%, p= 0.05). On multivariate analysis, ruptured ophthalmic artery aneurysms had 13-times higher odds for formation of SCM(OR 13.43 [1.22-147.8]; p= 0.02). Conclusion: aSAH with SCM predominantly occurred in postmenopausal females with larger aneurysms, and higher severity of bleeds. Ophthalmic artery aneurysms were associated with substantially increased risk of SCM after adjustment for aSAH severity. Despite similar treatment rates, SCM was associated with higher in-hospital mortality. These findings will require further confirmation in a larger subset of aSAH with SCM patients.

Endovascular treatment of an unruptured ophthalmic artery aneurysm with a flow diverter: a case report

An unruptured aneurysm is often asymptomatic or present without neurological deficits, causing severe morbidity. However, the potential of this defect to rupture requires proper management. Herein, we report a case of an unruptured saccular aneurysm of the ophthalmic artery with initial clinical seizures. The patient was treated by flow diversion which redirects the blood flow that normally leads to the protrusion of the aneurysm back to the main vessel. Flow diversion is chosen because it is less risky and has a faster recovery time than other treatment options, but it is more expensive than others. Although this technology is not new, there is no report on its implementation in Indonesia. The patient was prescribed antiplatelet treatment for at least 6 months post-treatment, then she showed no sign of seizure or new focal neurological deficits 4 months post-treatment. The patients were expected to undergo digital subtraction angiography evaluation 6 months after flow diversion treatment, but it has not been performed due to the coronavirus disease 2019 pandemic.

Direct Clipping of Paraclinoid Aneurysm in Conjunction with Extradural Anterior Clinoidectomy: Technical Nuance and Functional Outcome.

Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos. Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions. Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A ( p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B ( p = 0.030), respectively. However, it improved in the chronic phase. Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.

Role of the ophthalmic artery in the endovascular treatment for intracranial vascular diseases.

The ophthalmic artery (OA) is a crucial artery. Centered at the OA, there are numerous extracranial-intracranial anastomoses. The OA and its collaterals can be involved in some intracranial vascular diseases. So, it is very important to understand its specific anatomy, variation, and role in different neurovascular diseases. The OA has various anomalies both in the origin and collateral circulation. When performing endovascular treatment (EVT), the OA may suffer unexpected embolization through the numerous dangerous anastomoses. In case of a dural arteriovenous fistula or brain arteriovenous malformation mainly fed by the OA, the OA can be the passage of EVT, during which the central retinal artery could be injured. During interventional recanalization of steno-occlusive diseases of the internal carotid artery, dissection at the cavernous segment could progress to the OA segment and occlude the origin of OA. Under the circumstance of moyamoya disease, the OA can provide collateral flow to the anterior cerebral artery. When performing EVT for OA aneurysm concurrent with moyamoya disease, the parent OA should be preserved. After placement of a flow-diverting device for ophthalmic ICA aneurysm, the covered OA could experience spontaneous occlusion, leading to visual disturbance. Hence, the OA is an extremely important artery in the EVT for intracranial vascular diseases. In this article, we would extensively review the related literature to increase our understanding of the role of OA in intracranial vascular diseases. In addition, some illustrative cases would also be provided.