Central Retinal Artery Occlusion Due to Intraorbital Ophthalmic Artery Aneurysm

A 60-year-old woman experienced sudden onset of vision loss in her right eye. Neuroimaging studies initially were interpreted as tumorous compression of the right optic nerve. On referral to our institution, examination findings were that of a right central retinal artery occlusion (CRAO). Review of the previous imaging studies was consistent with an aneurysm of the intraorbital ophthalmic artery at the origin of the central retinal artery, which was believed to be the cause of the CRAO.

Photo Essay Section Editors: Melissa W. Ko, MD Dean M. Cestari, MD Central Retinal Artery Occlusion Due to Intraorbital Ophthalmic Artery Aneurysm Andrew R. Carey, MD FIG. 1. A. Precontrast axial T1 MRI shows a nodular lesion (arrow) superolateral to the right optic nerve, which demonstrates rim enhancement on postcontrast axial T1 with fat suppression (B). Axial (C) and sagittal (D) images of a computed tomographic angiogram reveals that the lesion fills with contrast (arrows) and is contiguous with ophthalmic artery at the origin of the central retinal artery. Abstract: A 60-year-old woman experienced sudden onset of vision loss in her right eye. Neuroimaging studies initially were interpreted as tumorous compression of the right optic nerve. On referral to our institution, examination findings were that of a right central retinal artery occlusion (CRAO). Review of the previous imaging studies was consistent with an aneurysm of the intraorbital ophthalmic artery at the Division of Neuro-ophthalmology, Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, Maryland. The author reports no conflicts of interest. Address correspondence to Andrew R. Carey, MD, Division of Neuroophthalmology, Wilmer Eye Institute, Johns Hopkins Medicine, 600 N. Wolfe Street, Baltimore, MD 21287; E-mail: [e-mail] Carey: J Neuro-Ophthalmol 2019; 39: 125-126 origin of the central retinal artery, which was believed to be the cause of the CRAO. Journal of Neuro-Ophthalmology 2019;39:125-126 doi: 10.1097/WNO.0000000000000698 © 2018 by North American Neuro-Ophthalmology Society A 60-year-old woman was evaluated in an emergency department for sudden onset of vision loss in her right eye and dizziness. Her blood pressure was 224/120 mm Hg. Brain MRI and MRA as well as computed tomographic angiography (CTA) of the head and neck were interpreted as showing a tumor of the right optic nerve. On referral to our medical center, visual acuity was counting fingers in the 125 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo Essay right eye and 20/20 in the left eye. A right relative afferent pupillary defect was present. Fundus examination of the right eye demonstrated macular whitening with a cherryred spot as well as arteriolar attenuation and venular boxcaring. Optical coherence tomography of the right macula confirmed the presence of subacute central retinal artery occlusion (CRAO) with hyperreflectivity and loss of lamellae of the inner retina including the inner nuclear layer and sparing of the outer retina. Review of the previous neuroimaging studies revealed a nodular lesion contiguous to the right optic nerve (Fig. 1A, B). CTA confirmed that the lesion was vascular and appeared to be connected to the ophthalmic artery (Fig. 1C, D) consistent with the diagnoses of an ophthalmic artery aneurysm. The patient has been monitored over 1 year with serial neuroimaging studies and has remained stable. Aneurysms are a rare cause of ischemic strokes. In a report of 269 patients presenting with a transient ischemic attack or stroke, only 3.3% of neurological events were attributed to aneurysm (1). Another series found that of patients found to have intracranial aneurysm, 5% had a stroke-like presentation (2). Cohen et al (3) identified 3 mechanisms of ischemic stroke because of unruptured aneurysm based on neuroimaging findings: dislodgement of thrombi in the aneurysm with distal embolization; extension of thrombus in the aneurysm into the parent vessel; and enlargement of the aneurysm and external compression of the distal vessel. 126 Intraorbital ophthalmic artery aneurysms are rare. They may be asymptomatic or cause vision loss, diplopia, or proptosis after hemorrhage (4). Surgical intervention includes clipping or parent vessel occlusion with trapping or resection. Another option is conservative management with regular follow-up, as occurred in our patient. Our patient's pain was likely due to enlargement of the intraorbital ophthalmic artery aneurysm in the setting of hypertensive urgency, and her vision loss was attributed to an embolic thrombus related to the aneurysm. To the best of our knowledge, CRAO has not been reported in association with an intraorbital ophthalmic artery aneurysm. REFERENCES 1. Qureshi A, Mohammad Y, Yahia A, Loft AR, Sharma M, Tamargo RJ, Frankal MR. Ischemic events associated with unruptured intracranial aneurysms: multicenter clinical study and review of the literature. Neurosurg. 2000;46:282-289. Discussion 289- 290. 2. Nanda A, Vannemreddy P. Cerebral ischemia as a presenting feature of intracranial aneurysms: a negative prognostic indicator in the management of aneurysms. Neurosurg. 2006;58:831-837. Discussion 831-837. 3. Cohen JE, Gomori JM, Leker RR. Thrombosis of non-giant unruptured aneurysms causing ischemic stroke. Neurol Res. 2010;32:971-974. 4. Della Pepa GM, Sabatino G, La Rocca G, Scerrati A, Maica G, Albanese A, Marched E. Intraorbital and intracanalicular ophthalmic artery aneurysms. Literature review and report of a case. Br J Neurosurg. 2014;28:787-790. Carey: J Neuro-Ophthalmol 2019; 39: 125-126 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.