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Show Post-traumatic Amaurosis Secondary to Paraophthalmic Internal Carotid Artery Pseudoaneurysm Treated With Pipeline Embolization Device James D. Kim, MD, Sean M. Barber, MD, Orlando M. Diaz, MD, Helen K. Li, MD, Robert E. Jackson, MD, Drew Hall, MD, Andrew G. Lee, MD Abstract: During evaluation for monocular visual loss, a 48-year-old woman was found to have a posttraumatic paraophthalmic internal carotid artery (ICA) pseudoaneur-ysm. She underwent reconstruction of the ophthalmic segment of the right ICA with a Pipeline embolization device but her vision did not return. Journal of Neuro-Ophthalmology 2013;33:359-362 doi: 10.1097/WNO.0b013e3182a30427 © 2013 by North American Neuro-Ophthalmology Society A48-year-old African American woman with a history of hypertension and a 15 pack-year smoking history expe-rienced an acute onset of visual loss in the right eye and retrobulbar pain 20 minutes after striking her right temple against a bed post. Review of systems was otherwise negative. She drove herself to an emergency room where computed tomography (CT) of the brain was normal and magnetic resonance imaging demonstrated mild induration of the intraconal fat and subtle enhancement of the optic nerve. She was instructed to see a neurologist as an outpatient, and 2 days later, her vision spontaneously returned to baseline. Two weeks later, the patient again acutely lost vision in her right eye and was admitted to a hospital where a temporal artery biopsy was negative. She was transferred to our facility and neurological examination was normal except for loss of vision in the right eye. Visual acuity was light perception, right eye, and 20/30, left eye. Pupillary examination revealed a right relative afferent pupillary defect. Intraocular pressure was normal in both eyes as was the left visual field. The right fundus revealed splinter hemorrhages, segmental arteriolar narrowing, optic disc pallor, and macular ischemia with a prominent cherry red spot in the macula (Fig. 1). The left fundus was unremark-able. Fluorescein angiography demonstrated delayed choroi-dal and optic disc perfusion in the right eye (Fig. 2). The constellation of clinical findings were consistent with a right ophthalmic artery occlusion. Within a few days, vision in the right eye was no light perception. FIG. 1. The left fundus (A) appears normal while on the right (B) there is a swollen disc and opacification of the retinal nerve fiber layer and a cherry red spot in the macula. Department of Ophthalmology and Visual Sciences (JDK), University of Texas Medical Branch, Galveston, Texas; Departments of Neuro-logical Surgery (SMB) and Interventional Neuroradiology (OMD), Methodist Neurological Institute, Houston, Texas; Department of Ophthalmology (HKL, AGL), Weill Cornell Medical College, New York, New York; School of Bioinformatics (HKL), The University of Texas Health Science Center, Houston, Texas; Department of Ophthalmol-ogy (HKL), Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Ophthalmology (HKL, AGL), The Methodist Hospital, Houston, Texas; Department of Medicine (REJ, DH), The Methodist Hospital Research Institute, Houston, Texas; Department of Medicine (REJ), Weill Cornell Medical College, New York, New York; Depart-ment of Ophthalmology (AGL), Baylor College of Medicine, Houston, Texas; Departments of Ophthalmology, Neurology, and Neurosurgery (AGL), Weill Cornell Medical College, New York, New York; and Department of Ophthalmology (AGL), The University of Iowa Hos-pitals and Clinics, Iowa City, Iowa. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, NY. The authors report no conflicts of interest. Address correspondence to Andrew G. Lee, MD, Department of Ophthalmology, The Methodist Hospital, 6560 Fannin Street, Scur-lock 450, Houston, TX 77030; E-mail: aglee@tmhs.org Kim et al: J Neuro-Ophthalmol 2013; 33: 359-362 359 Photo Essay Section Editor: Timothy J. McCulley, MD Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Laboratory workup yielded normal results for erythro-cyte sedimentation rate, anti-nuclear antibody, perinuclear anti-neutrophil cytoplasmic antibody, and cytoplasmic antinuclear cytoplasmic antibody, vitamin B12 and folate, rapid plasma reagin, thyroid function, lipid profile, liver function studies, and hypercoaguable panel. Transthoracic echocardiogram, electrocardiogram, and carotid Doppler failed to reveal a source of thromboemboli. Magnetic resonance angiogram (MRA) and magnetic resonance venogram were normal as was cerebrospinal fluid analysis. Cerebral angiography demonstrated nonvisualization of the origin of the right ophthalmic artery from the right internal carotid artery (ICA) with distal refilling of the ophthalmic artery via flow from the meningolacrimal branch of the right middle meningeal artery. In addition, there was a 1.73 · 1.75 mm irregular dilation of the ophthalmic segment of the right ICA associated with distal narrowing of the right supraclinoid ICA, consistent with dissecting pseudoaneur-ysm (Fig. 3). A Pipeline embolization device (PED; Covidien Vascular Therapies, Mansfield, MA) was positioned within the supraclinoid ICA from the level of the anterior choroidal artery extending into the anterior genu of the cavernous ICA. Angiography performed following embolization dem-onstrated complete obliteration of the pseudoaneurysm (Fig. 4). The patient's vision in the right eye remained unchanged 12 months later. Ophthalmic artery occlusion is uncommon and com-promises blood flow to the retinal and choroidal circu-lations. It is usually due to embolic phenomena related to atherosclerotic disease, myxoma, mural thrombus, or vasculitis (1). Our patient's vision returned to baseline 2 days after the initial presentation and was subsequently lost a second time. This may be explained by the hypothesis of Duker and Brown (2) that ophthalmic artery occlusion often causes hypoperfusion of choroidal and retinal vessels, thus compromising retinal cell function without necessarily causing cell death. It is likely that retinal perfusion recov-ered because of resolution of the initial thromboembolic occlusion but a second thromboembolic event resulted in permanent loss of vision. A less likely explanation is that visual loss may have resolved and recurred because of oph-thalmic artery vasospasm, which is known to occur in the setting of trauma. Traumatic intracranial aneurysms are rare (3-5) and result from shearing of intracranial vessels due to rapid deceleration forces (5). Arteries arising nearby may become occluded because of local thromboembolism, hemodynamic compromise, and changes in vessel morphology brought about by aneurysmal expansion and dissection (6). Mortal-ity secondary to rupture of traumatic intracranial aneurysms approaches 50% in the first 3 weeks (7-9), necessitating prompt treatment. These aneurysms are less amenable to surgical intervention or endovascular coil embolization because of their thin walls, wide necks, and propensity for intraoperative rupture (10,11). The PED is an implantable, platinum-based mesh conduit designed to divert arterial flow away from the aneurysm, resulting in intra-aneurysmal hemostasis and thrombosis. Parent vessel reconstruction with the PED was decided upon in our patient for its ability to treat the pseudoaneurysm without the need for aneurysmal catheter-ization and without risk of coil migration. Computed tomography angiography (CTA) and MRA are favored over conventional angiography as an initial screening method for intracranial vascular pathology because of their increased availability and lower frequency of complications. However, traumatic intracranial aneur-ysms often are small in size (3,8,12,13), and CTA and MRA have a sensitivity of 30%-60% for aneurysms ,5 mm in size (14). Therefore, patients suspected of post-traumatic pseudoaneurysm may require cerebral catheter angiography for both diagnosis and treatment. FIG. 2. Fundus fluorescein angiography. A. Right eye: Two minutes after injection, there is delayed perfusion and hypo-perfusion of choroidal and retinal vessels and the optic disc. B. Left eye: At 1:13 minutes, there is normal perfusion of the choroid and retina. 360 Kim et al: J Neuro-Ophthalmol 2013; 33: 359-362 Photo Essay Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. FIG. 4. Six months after Pipeline device embolization. Top panel: Digital subtraction angiography (DSA). Bottom panel: Three-dimensional reconstructed images of DSA. Anteroposterior (A) and lateral (B) DSA images show that the dissecting pseudoa-neurysm has been completely obliterated and the distal ICA stenosis has resolved (arrows). Lateral skull radiograph (C) shows the Pipeline embolization device in position within the ophthalmic segment of the right internal carotid artery (ICA; arrow). Townes view of DSA following a right external carotid injection (D) shows that the right ophthalmic artery continues to be filled distally by the meningolacrimal branch of the right middle meningeal artery (arrow). Anteroposterior superior (E, F) and lateral (G) and ante-roposterior caudal (H) reconstructed images following right ICA injection. The dissecting pseudoaneurysm has been obliterated, and the distal ICA stenosis has resolved (arrows). The origin of the right ophthalmic artery from the right ICA still is not visualized. FIG. 3. Top panel: Digital subtraction angiography (DSA). Bottom panel: Three-dimensional reconstructed images of DSA. A broad-based ophthalmic segment aneurysm is present with irregular contour (A, arrowhead) and mild narrowing of the distal supraclinoid internal carotid artery (ICA) (arrow) (B, arrow). The origin of the right ophthalmic artery from the right ICA is not visualized. Townes view (C) and lateral images (D) following right internal maxillary artery injection reveals the right ophthalmic artery filling distally from the meningolacrimal branch of the right middle meningeal artery (arrow). Anteroposterior superior (E, F), lateral (G), and ante-roposterior caudal (H) reconstructed images of right ICA injection demonstrates a broad-based 1.73 · 1.75 mm dilation of the ophthalmic segment of the right ICP (arrowheads) with irregular contour and broad-based neck with mild narrowing of the distal supraclinoid ICA (arrows). The origin of the right ophthalmic artery from the right ICA is not visualized. Kim et al: J Neuro-Ophthalmol 2013; 33: 359-362 361 Photo Essay Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. REFERENCES 1. Brown GC, Magargal LE, Sergott R. Acute obstruction of the retinal and choroidal circulations. Ophthalmology. 1986;93: 1373-1382. 2. Duker JS, Brown GC. Recovery following acute obstruction of the retinal and choroidal circulations. A case history. Retina. 1988;8:257-260. 3. Parkinson D, West M. Traumatic intracranial aneurysms. J Neurosurg. 1980;52:11-20. 4. 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