Treatment Of Ophthalmic Segment Aneurysms Research Articles

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.

Ophthalmic Segment Aneurysms: Surgical Treatment and Outcomes.

Background Surgical treatment of ophthalmic segment aneurysms (OSAs) remain challenging because of complex anatomy surrounding the aneurysm and entails extensive drilling of anterior clinoid process to define proximal neck of the aneurysm and carotid exposure in the neck for proximal control. Materials and Methods Authors present a retrospective analysis of 36 aneurysms in 35 patients with OSAs operated surgically by first author. Surgical clipping was done for the aneurysms as primary modality of treatment along with wrapping and trapping as required. Results Commonest age group was 40 to 60 years with female preponderance of 3:1. Maximum (23) patients presented with subarachnoid hemorrhage (WFNS Gr 1), followed by asymptomatic patients (six). There were 18 small, 14 large, and four giant aneurysms, 15 dorsal wall, 17 ventral wall, three proximal posterior wall, and one blister aneurysm. Good outcome, as measured by Glasgow Outcome Score (GOS) was achieved in 29 patients. Conclusion OSAs are technically demanding aneurysms, but with due diligence to surgical principles, good outcomes may be obtained.

Flow-diverting devices in the treatment of unruptured ophthalmic segment aneurysms at a mean clinical follow-up of 5\xa0years

A shift toward the endovascular treatment of ophthalmic segment aneurysms is noticeable. However, it is not clear if the long-term treatment results improve with the development of endovascular methods. The aim of this study was to present the outcomes of the treatment of unruptured ophthalmic aneurysms using flow diverting devices (FDD) with or without coiling. This retrospective study included 52 patients with 65 UIAs treated in 2009–2016. The mean aneurysm size was 8.8 mm. Eight aneurysms were symptomatic. Therapeutic procedures included: 5 failed attempts, 55 first sessions with FDD deployment (bilateral procedures in 3) and 3 retreatment procedures. To cover 55 ICAs, 25 Silk, 26 Pipeline, 9 Fred and 1 Surpass FDD were used. FDD with coiling was applied in 19(29.2%), mainly for symptomatic and larger aneurysms. Mean radiological and clinical follow-up was 12 and 61 months, respectively. Postprocedural deterioration was noted in 3(5.8%) patients, but in long-term the modified Rankin Scale grades 0–2 were achieved in 98.1% of patients. One patient died from the treated aneurysm rupture (annual risk—0.07%). Raymond–Roy occlusion classification class I or II was achieved in 98.5% in the long term, with similar results in both groups. Complications occurred in 40.4% of patients and the most frequent were: imperfect FDD deployment (15%), failed attempt of FDD deployment (9.6%) and late FDD stenosis (9.6%). Flow-diverting devices, with additional coiling in selected cases, may offer a very high proportion of satisfactory outcomes. However, in our experience the high risk of complications remains.

Hemodynamic impacts of flow diverter devices on the ophthalmic artery

BackgroundFlow diverter devices are increasingly used for endovascular treatment of internal carotid artery aneurysms. Treatment of ophthalmic segment aneurysms with flow diverter devices also includes coverage of the ophthalmic artery but may result in complications. It is unclear, however, whether these devices mechanically block blood flow in the ophthalmic artery. Also unclear is the relationship between deployment of a flow diverter device and post-treatment occlusion. We studied hemodynamic changes in the ophthalmic artery after deployment of a flow diverter device to determine the relationship between those changes and post-stent occlusion of the artery.MethodsWe analyzed hemodynamic modifications in the ophthalmic artery in 21 patients (19 women, 2 men; mean age 53.43 ± 7.32 years) treated by a single pipeline embolization device. Patient-specific geometries were determined from three-dimensional digital subtraction angiography and the stenting process was simulated. Computational fluid dynamics technology was used to analyze the change in ophthalmic artery hemodynamics. We compared pre-treatment and post-treatment flow velocity of the ophthalmic artery.ResultsAmong the 21 patients with aneurysms located in the ophthalmic segment, no ophthalmic artery occlusion was found during immediate or follow-up angiography. Post-stent flow velocity in the ophthalmic artery decreased from 0.35 ± 0.19 to 0.33 ± 0.20 m/s, with the difference not being statistically significant (P = 0.106).ConclusionOur results showed no significant change in ophthalmic artery blood flow after pipeline embolization device deployment. Hence, post-stent occlusion of the ophthalmic artery could not be explained by reduced blood flow. Delayed thrombosis and neointimal formation maybe the keys to ophthalmic artery occlusion and need further investigation.

Comparison of Stent-Assisted Coil Embolization and the Pipeline Embolization Device for Endovascular Treatment of Ophthalmic Segment Aneurysms: A Multicenter Cohort Study.

Stent-assisted coil embolization and flow diversion with the Pipeline embolization device (PED) are both effective endovascular treatment options for ophthalmic segment aneurysms (OSAs) of the internal carotid artery. Here we present a large comparative cohort study. A multicenter, retrospective cohort comparison study of consecutively treated OSAs was conducted at 2 academic institutions in the United States comparing stent-coiling (between 2007 and 2015) and PED (between 2011 and 2016). A total of 62 of OSAs were treated with stent-coiling and 106 were treated with the PED. The stent-coiling-treated aneurysms were larger, although the maximum diameter was not significantly different between the 2 groups (P= 0.05). The median duration of follow-up was 22.5 months for the stent-coiling group and 8.7 months for the PED group (P= 0.0002). Complete occlusion at last follow-up was achieved in 75.9% of aneurysms in the stent-coiling group and in 81.1% of aneurysms in the PED group (P= 0.516). The retreatment rate was higher with stent-coiling, but the difference did not reach statistical significance (P= 0.062). A good functional outcome was achieved in 96.6% of patients in the stent-coiling group and in 94.7% of those in the PED group (P= 0.707). The rate of neurologic complications was 4.8% in the stent-coiling group and 9.4% in the PED group (P= 0.376). Stent-coiling and the PED were equally effective for treating OSAs. There were no significant differences in terms of procedural complications, angiographic, functional, and visual outcomes. PED may be more favorable for multiple adjacent OSAs.

Flow Diverters for Treatment of 160 Ophthalmic Segment Aneurysms: Evaluation of Safety and Efficacy in a Multicenter Cohort

Treatment of ophthalmic segment aneurysms (OSA) remains challenging. Flow diverter stents (FDS) have evolved as a promising endovascular treatment option for aneurysms of the internal carotid artery and are associated with high occlusion rates and a favorable morbidity and mortality profile. To determine safety and efficacy of FDS for OSA in a large, multicenter cohort. A retrospective analysis of prospectively maintained databases of 127 consecutive patients harboring 160 OSA treated with FDS was performed. Aneurysms were classified based on location and morphology. Follow-up with digital subtraction angiography (DSA) was performed 6 to 18 months after treatment. Follow-up DSA was available for 101 (63.1%) aneurysms with a mean follow-up of 18 months. Complete occlusion was observed in 90 aneurysms (89.1%), near-complete occlusion (>95%) in 3 (3%), and incomplete occlusion (<95%) in 8 aneurysms (7.9%). One aneurysm was retreated with another FDS (0.9%). No risk factors for incomplete occlusion were identified. The OA was occluded at the latest follow-up in 6 cases (7.1%). Permanent morbidity occurred in 4 patients (3.1%), and there was no mortality related to the FDS procedure. Treatment of OSA with FDS was found to be safe and effective. The retreatment rate was extremely low and aneurysms that occluded did not reanalyze.

Flow-diversion for ophthalmic segment aneurysms.

The use of flow-diversion to treat ophthalmic segment aneurysms (OSA) has not been well evaluated. To assess the visual outcomes, the obliteration rate, and the need for retreatment of OSA treated by the pipeline embolization device (PED). Patients who underwent treatment with PED for OSA from 2009 to 2014 were selected and retrospectively reviewed. Patient's age, sex, mode of presentation, and aneurysm size were recorded. The complication rates, the need for retreatment (due to recurrence of the aneurysm or worsening symptoms), the aneurysm occlusion rates, the evolution of visual symptoms, and the evolution of headache/retro-orbital pain were registered. Forty-one patients harboring 44 OSA treated by flow-diversion were identified. Females constituted 87.80% (37/41) of the cohort. The mean age was 59.16 ± 12.54 years. At final angiographic follow-up, 77.27% (34/44) had complete occlusion, 6.81% (3/44) had near-complete occlusion, and 15.90% (7/44) had incomplete occlusion. Of the 22 symptomatic OSA, complete resolution or significant improvement was noted in 72.72% (16/22), while worsening of symptoms occurred in 4.54% (1/22). Five patients out of 22 (22.72%; 5/22) had no significant changes in their symptoms. The complication rate was 2.27% (1/44). The mortality rate was 0%. The low complication rate, the high obliteration rate, and the high rate of improvement in the visual symptoms make flow-diversion an appealing option for the treatment of OSA.

Resolution of Diminished Olfactory Sensation After Treatment of Bilateral Ophthalmic Segment Aneurysms With Flow Diversion

Olfactory tract dysfunction due to an unruptured intracranial aneurysm is rare. We present a case in which a patient with impaired olfaction related to bilateral internal carotid artery aneurysms experienced subjective and quantitative objective improvement of olfactory sensation after treatment of ophthalmic segment aneurysms with flow diversion. A 44-year-old woman presented with hyposmia and bilateral ophthalmic segment internal carotid artery aneurysms. The symptom of hyposmia, worsening over a period of several months, was suspected to be due to mass effect from bilateral unruptured ophthalmic segment aneurysms pressing on the olfactory tracts. Each aneurysm was treated with a Pipeline embolization device (PED). Follow-up angiography at 5 months showed occlusion of both aneurysms. The patient experienced subjective improvement in olfaction and complete objective resolution of her hyposmia as measured by the validated University of Pennsylvania Smell Identification Test (UPSIT). Intracranial aneurysms causing dysfunction of olfactory sensation due to mass effect upon the olfactory tract can be successfully treated with flow diversion. Flow diversion should be considered as one of the treatment options for patients with cranial nerve dysfunction due to unruptured intracranial aneurysms.

Microsurgical treatment of ophthalmic segment aneurysms

Ophthalmic segment aneurysms refer to superior hypophyseal artery aneurysms, true ophthalmic artery aneurysms, and their dorsal variant. Indications for treatment of these aneurysms include concerning morphological features, large size, visual loss, or rupture. Although narrow-necked aneurysms are ideal endovascular targets, more complex and larger lesions necessitating adjunctive stent or flow-diversion techniques may be suitably treated with long-lasting, effective clip ligation instead. This is particularly relevant in the consideration of ruptured ophthalmic segment aneurysms. This article provides a depiction of microsurgical treatment of ophthalmic segment aneurysms with an accompanying video demonstration. Emphasis is placed on microsurgical anatomy, the intradural anterior clinoidectomy and clipping technique. The intradural anterior clinoidectomy, demonstrated in detail in our Supplementary video, provides significant added exposure of the ophthalmic segment of the internal carotid artery, allowing for improved aneurysm visualization. In the management of superior hypophyseal artery aneurysms, emphasis is placed on identifying and preserving superior hypophyseal artery perforators, using serial fenestrated straight clips rather than a single right-angled fenestrated clip to obliterate the aneurysm. Post-clipping indocyanine green dye angiography is a crucial tool to confirm aneurysm obliteration and the preservation of the parent vasculature and adjacent superior hypophyseal artery perforators. With careful attention to the nuances of microsurgical clipping of ophthalmic segment aneurysms, rewarding results can be obtained.

Microsurgical treatment of ophthalmic segment aneurysms of internal carotid artery: 28 cases report

To investigate the operative modalities and outcomes of 28 cases of ophthalmic segment aneurysms of internal carotid artery. Twenty-eight cases of ophthalmic segment aneurysms of internal carotid artery were operated on from May 2004 to August 2009. Of all 28 cases, 20 were large or giant. Nineteen aneurysms were directly clipped or resected with internal carotid artery revascularization. Since 2006, high-flow extracranial-intracranial (EC-IC) bypass were available and performed in 9 patients of large or giant aneurysms and then the aneurysms were resected or trapped. Seventeen patients underwent digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance angiography (MRA) postoperatively. The images demonstrated that 5 grafts of bypass were in patency, and 2 were occluded. Only 1 aneurysm was partially clipped and the others disappeared on imaging. The 78% of these cases had good results (GOS 4-5). One patient died after EC-IC bypass due to neck hematoma. The treatment of ophthalmic segment aneurysms of internal carotid artery, especially the large and giant ones, remains a challenge for neurovascular neurosurgeon. The accessory high-flow EC-IC bypass procedures and selection of suitable aneurysm clips are very important to improve the effectiveness of the operation.

Outcome following surgery for ophthalmic segment aneurysms

Ophthalmic segment aneurysms account for about 5% of all intracranial aneurysms. Anatomical complexity of the paraclinoid region makes surgical management of aneurysms arising from the ophthalmic segment challenging. This study was carried out to assess the presenting features, complications and outcomes after surgical treatment of ophthalmic segment aneurysms. The authors retrospectively analysed the clinical records of patients with ophthalmic aneurysms treated at our Institute from January 2001 to September 2008, which constituted about 9% (78/850) of all intracranial aneurysms. Of the 78 ophthalmic segment aneurysms, six patients (8%) had giant aneurysms and 19 (24%) patients had multiple aneurysms. Fifty-six patients underwent microsurgery, with direct clipping in most. The mean age was 42 years (range 12–75 years) and the mean follow-up was 8 months (range, 2–93 months). A good outcome was achieved in 46 (83%) patients (Glasgow Outcome Scale [GOS] score 4–5) and 17% had a poor outcome (GOS score 1–3) at last follow-up. The overall complication rate was 21% (12/56), most of which were transient complications, with 3.5% (2/56) mortality. Direct microsurgical clipping remains our preferred treatment approach, whenever possible, for ophthalmic segment aneurysms. This surgery has an acceptable complication rate and leads to a good outcome in more than 80% of patients with ophthalmic aneurysms. Use of modern microsurgical instrumentation and endovascular adjuncts can further reduce the surgical morbidity associated with these vascular lesions.

Abstracts of Literature

Abstracts of Literature