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Show ]. Clin. Neuro-ophthalmol. 3: 91-96, 1983. Muslin Wrapping of Aneurysms and Delayed Visual Failure A Report of Three Cases P. G. CARNEY P. E. OATEY Abstract This article reports three cases of visual failure of presumably ischemic etiology, after aneurysm surgery; the first case occurring 7 months after clipping and gauze wrapping of a 4-mm anterior communicating artery aneurysm; the second case occurring 8 months after gauze wrapping of a partially intracavernous 10mm internal carotid artery aneurysm which projected into the right optic foramen; and the third case occurring 11 months after ligation, clipping, and gauze wrapping of an 8-mm internal carotid-posterior communicating artery aneurysm. Introduction We report three puzzling cases of visual failure which occurred 7,8, and 11 months after aneurysm surgery. Fortunately, after initial disturbing and severe progressive visual deterioration in two cases, considerable recovery occurred. Such visual failure many months after aneurysm surgery is, in our experience (and to our knowledge), an unrecognized phenomenon. Its etiology remains uncertain. Case Reports Case I F.M., female, aged 44 years, presented in September 1978 with a several-year history of formed visual hallucinations. On examination there were no abnormal signs. A diagnosis of left temporal lobe epilepsy was made. During investigation a CT scan revealed an aneurysm in the right parasellar region (Fig. 1). Carotid and vertebral angiography confirmed a IS-mm diameter right internal carotid- anterior choroidal artery aneurysm as well as a 4-mm diameter anterior communicating artery aneurysm (Figs. 2 and 3). In September 1978, both aneurysms were clipped successfully. Supplementary gauze was wrapped around the neck of the From the Department of t'-:eurosurgerv. Royal Adelaide Hospital. Adelaide, S.A, Australia. June 1983 anterior communicating artery aneurysm (Figs. 4 and S). The patient recovered and remained well until 7 months postoperatively, when she presented with an 8-day history of mild bitemporal headache and progressive blurring of vision. Her visual fields deteriorated for 16 days (Fig. 6), then rapidly improved over several days with good functional visual recovery. The only residual deficit was a partial temporal field defect to red in the right eye. Bilateral carotid angiography, CT scan, and air encephalography, with special reference to the chiasmatic cistern, were negative. ESR was 16 mm, CSF examination revealed two lymphocytes and four erythrocytes and a normal protein, and the patient remained afebrile. Case 2 V.K., female, aged 47 years, presented in October 1979 with a 3-month history of vague headache and confusion, culminating in a probable epileptiform seizure. The only positive finding on examination was a weakly extensor right plantar reflex. A CT scan revealed a 3-cm diameter left and central subfrontal meningioma (Fig. 7), as well as a right internal carotid artery aneurysm (Fig. 8), confirmed by carotid angiography to lie below the anterior clinoid process (Fig. 9). On September 10, 10 70 , a grade 2 removal of the meningioma was achieved. Two weeks later, a surgical attack on the aneurysm was performed. The 10-mm diameter aneurysm lay partially within the cavernous sinus, and projected into the right optic foramen (but was not obviously compressing the right optic nerve) with the ophthalmic artery looping over it. The aneurysm was gauze-wrapped because of its location. The patient recovered well. In November 1979, 3 weeks after the wrapping of the aneurysm, the patient complained of sudden loss of vision in the right eye. This subsequently fluctuated in severity; however, when she was admitted and examined 2 days later, visual acuity and fields were normal. Carotid angiography revealed no change and the patient was discharged with a diagnosis of optic nerve ischaemia. 91 Aneurysms and Visual Failure Figure 1. CT scan showing the right parasellar aneurysm. Figure 2. Right carotid angiogram showing the internal carotidanterior choroidal artery aneurysm. In June 1980, 8 months after the wrapping of the aneurysm, cloudiness of vision in the right eye developed, lasting 3 weeks, and then worsening over 2 days, such that she could barely see light with her right eye. Concomitant with this, vision in her left temporal field also disappeared. Examination revealed a severely decreased right visual acuity and a right visual field defect in all quadrants, but more marked inferiorly. There was a left 92 Figure 3. Vertebral angiogram showing the anterior communicating artery aneurysm. Figure 4. Postoperative right carotid angiogram showing both clips, the lower one obliterating the internal carotid-anterior choroidal artery aneurysm. temporal hemianopia with only moderately impaired left visual acuity (Fig, 10). Subsequently vision spontaneously improved. The left eye returned to normal 2 weeks after the onset of the left visual disturbance while the right eye 3 months later showed a still-reduced although improved visual acuity of 20/120 with an inferior field defect. The patient exhibited a pyrexia of 38.7° for the initial 4 days of admission; CSF examination revealed eight polymorphonuclear leucocytes, 23 lymphocytes, and 58 erythrocytes. CSF protein was normal and ESR was 14, A CT scan and carotid angiography showed no change in the size of the aneurysm, and no evidence of any other mass lesion in the region of the optic nerve or chiasm. Journal of Clinical Neuro-ophthalmology Figure 5. Postoperative carotid angiogram showing both clips obliterating the internal carotid-anterior choroidal and anterior communicating artery aneurysms. o~%o o~% 101t- :26·5.7'1' -500 I 0 ,...--~ I (!J l) I~~OO 2;!I-5-1i' 19 ,-7>- 0 1(1%"000 Figure 6. Visual fields (F.M., case 1). June 1983 Carney,Oatey Figure 7. CT scan showing the left and central subfrontal meningioma. Figure 8. CT scan showing the right internal carotid artery aneurysm. 93 Aneurysms and Visual Failure Figure 9. Carotid angiogram (following meningioma removal) showing the right internal carotid artery aneurysm. Figure 11. Carotid angiogram showing the ovoid left posterior communicating artery aneurysm. Case 3 J.H" female, aged 37 years, presented in November 1979 with progressive right-sided weakness associated with an articulatory dyspraxia, initially of sudden onset, but without headache. Bilateral carotid angiography revealed a spontaneous dissection of the left internal carotid artery in its terminal third up to the skull base. There was also an irregular ovoid left posterior communicating artery aneurysm measuring 8 mm X 6 mm X 7 mm projecting posteroinferiorly (Fig. 11), and a right Figure 12. Carotid angiogram (following clipping of the left posterior communicating artery aneurysm) showing the right intracavernous internal carotid artery aneurysm. () VA%2 n_VA 1%0 FINGER., ----=-=CO-N-FRONTATION T -- O.A% : ~.A"" FINGER -JP CONFRONTATION Fig. 10 Figure 10. Visual fields (V.K., case Z). G 25 - 8 - 80 E 8-7 -80 o 5 -7 - 80 () VA% I A VA 1;0 FINGER \:::I CONFRONTATION ,_.O.A~.J ~-~.A~ 12-7-80 . __ .__ ~O _ R A 0 0 )-10-79 ---_. 8 0 20-11-79 TRANSIENT C 0 JUNE 80 94 Journal of Clinical Neuro-ophthalmology VA 9f 5 L A 6 - 8- 81 6 VA 1"2 R 0 ,, _,,. , ,, . ,,, ' ... - ....... Carney, Gatey B 17- 8 - 81 6 VA 1"2 Fig. 13 VA 9f 5 Figure 13. Visual fields (J.H., case 3). Figure 14. Carotid angiogram showing complete occlusion of the left posterior communicating artery aneurysm. intracavernous aneurysm measuring 5 mm X 3 mm (Fig. 12). A CT scan confirmed an infarct in the distribution of the left middle cerebral artery. Within 2 weeks the patient was discharged with only minimal right-sided neurological signs. Three months later, a left frontotemporal craniotomy was performed to obliterate the left internal carotid artery aneurysm which arose at the level of the posterior communicating artery. The broad base was initially ligated with silk and then clipped with a Heifetz clip. Because of several small blebs on the internal carotid artery, gauze wrapping was applied to the neck and adjacent internal carotid artery. She recovered well and was discharged with no increase in her mild neurological signs. The patient remained well until 11 months postoperatively when she noted left visual disturbance while applying cosmetics with her right eye closed. June 1983 Over the next 3 weeks, progressive left nasal field impairment occurred and initial examination revealed a left nasal paracentral scotoma. Visual acuity was 20/20. Five months later vision had deteriorated to 20/120 in the left eye, visual acuity in the right eye remaining normal. There was now a complete left nasal field loss with slight extension across the midline (Fig. 13). Bilateral carotid angiography was performed and showed no change in the right intracavernous aneurysm. There was complete occlusion of the left internal carotid artery aneurysm (Fig. 14). The patient was afebrile and cerebrospinal fluid was not examined. On discharge 6 months after the onset of visual difficulty, visual acuity was 20/40 in the left eye, the nasal field defect still crossing the midline by several degrees. Some blurred shapes were visible in the inferior left nasal field, the superior nasal field being most affected (Fig. 13). The residual minimal right-sided neurological signs remained unchanged. Discussion The loss of vision in the three cases suggested pathology in the optic nerves and chiasm. The onset was not sudden and complete, but had an element of progression. This seemed unlikely to be due to a single embolus, although repeated small emboli may theoretically produce such a progression. All cases had gauze wrapping around an aneurysm in close proximity to the optic nerves and chiasm and perforating vessels. Only case 2, however, showed a CSF pleiocytosis; however, this and the fever may be significant. Perhaps arachnoiditis, with vascular occlusion of small vessels to the optic nerves and chiasm, consequent upon the use of the 95 Aneurysms and Visual Failure gauze, is the explanation. Slight enlargement of the aneurysm by thrombosis (not, therefore, visible on angiography and difficult to detect on the CT scan) with local pressure on the optic apparatus seems unlikely. Thrombosis of small vessels arising close to the neck of the aneurysms may be worth considering, although in case 2, the aneurysm had not changed in size. Direct clip pressure is an unlikely cause (in case 2, no clip was used). In any event, an ischaemic process seems likely; however, its initiation is obscure. The process may be related to the use of gauze; however (in our experience), other patients have not demonstrated such visual deterioration following its application. Pool has noted the use of muslin gauze in achieving hemostasis in intracranial vascular surgery.' Sachs showed that cotton induced firm fibrous encasement around intracranial carotid arteries by 3 weeks in dogs,2 and Taylor and Choudhury report the chief merit of gauze to be its freedom from producing infarcts. This, however, was with reference to ruptured aneurysms of the middle cerebral artery.3 The optic apparatus may be a more sensitive indicator of small vessel occlusion. Although spontaneous recovery occurred in the first two cases, in one of these visual acuity re- 96 mained significantly impaired in the right eye. In the third case, significant recovery of the nasal field loss has not occurred in 6 months since its onset. References 1. Pool, J.L.: Muslin gauze in intracranial vascular surgery. (Technical note.) f. Neurosurg. 44: 127-128, 1976. 2. Taylor, J.c., and Choudhury, A.R.: Reinforcement with gauze wrapping for ruptured aneurysms of the middle cerebral artery. f. Neurosurg. 47: 828-832, 1977. 3. Sachs, E., Jf.: The fate of muscle and cotton wrapped about intracranial carotid arteries and aneurysms. A laboratory and clinicopathological study. Acta Neurochir. 26: 121-137,1972. Acknowledgment The authors thank the Neurosurgery Department of the Royal Adelaide Hospital and Deidre Cain for the diagrams. Write for reprints to: P. G. Carney, Department of Neurosurgery, Royal Adelaide Hospital, North Terrace, Adelaide, S.A., 5001, Australia. Journal of Clinical Neuro-ophthalmo(ogy |
