Retinal artery occlusion

Retinal artery occlusion

Etiology

Postoperative visual loss.

Retinal artery occlusion (RAO) is rarely seen as a complication in patients undergoing carotid artery stenting (CAS); hence, its characteristics have not been documented in detail.

A study of An et al. aimed to investigate the incidence of this complication and the related risk factors, focusing on differences in ophthalmic artery (OA) supply (whether by the external carotid artery or internal carotid artery [ECA or ICA]) prior to CAS procedures.

They retrospectively examined 342 patients who underwent CAS for severe and/or symptomatic carotid artery stenosis between January 2009 and December 2017. Cumulative medical records and radiologic data were assessed. RAO was confirmed by photography and fluorescent angiography of the fundus, which were performed by an ophthalmologist. In all patients, distal filter systems of various types were applied as cerebral protection devices (CPDs) during procedures. Univariate and multivariate analyses were conducted to identify the risk factors for RAO after CAS.

Symptomatic RAO was observed in six patients (1.8%), of which five (6.8%) were ECA-dominant group members (n = 74). In a binary logistic regression analysis, OA supply by the ECA (odds ratio [OR], 9.705; 95% confidence interval [CI], 1.519-62.017; p = 0.016) and older age (OR, 1.159; 95% CI, 1.005-1.336; p = 0.041) were identified as significant risk factors in patients with RAO after CAS. ECA-supplied OA was also associated with the severity of ipsilateral ICA stenosis (p = 0.001) and ulcerative plaque (p = 0.021).

In procedures performed using ICA distal filtering CPD systems, RAO as a complication of CAS (performed for severe stenosis) showed a relationship to ECA-supplied OA. For older patients, simultaneous use of ICA-ECA CPDs might help prevent such complications 1).

Case reports

A 50 year-old man on immunosuppressive agents presented with left eye vision loss, periorbital swelling, pain, and ophthalmoplegia. The patient was clinically found to have a central retinal artery and vein occlusion. A CT scan was performed which demonstrated intraorbital fat stranding, however the patient lacked sinus disease. The etiology of the orbital infection was held in question. The area was debrided in the operating room, and the specimen demonstrated group A streptococcal species consistent with necrotizing fasciitis. Periorbital necrotizing fasciitis should be suspected in patients with rapidly progressive orbital symptoms without sinus disease as lack of surgical intervention can result in poor outcomes. The unusual aspect to this case is the mechanism of vision loss, as the authors hypothesize that there was vascular infiltration of the infection resulting in the central retinal artery occlusion and central retinal vein occlusion which have not been previously reported secondary to necrotizing fasciitis of the orbit 2).


Elkordy et al. reported a patient with an unruptured ophthalmic artery aneurysm which treated with endovascular coiling and was complicated by blindness due to OphA thromboembolic occlusion after the procedure. The OphA successfully recanalized using local intra-arterial fibrinolysis with complete regain of visual acuity. The risk of visual loss due to thromboembolic complications cannot be ignored during the endovascular coiling of the OphA aneurysm despite good retrograde flow during OphA occlusion test using a balloon catheter. Rapid intervention is required for recovering visual disturbance in such a situation 3)

References

1)

An SJ, Cho YD, Lee J, Mun JH, Yoo DH, Kang HS, Yang YJ, Han MH. Symptomatic Retinal Artery Occlusion after Angioplasty and Stenting of the Carotid Artery: Incidence and Related Risk Factors. Korean J Radiol. 2019 Nov;20(11):1546-1553. doi: 10.3348/kjr.2019.0030. PubMed PMID: 31606959.
2)

Sultan H, Malik A, Li HK, Chévez-Barrios P, Lee AG. Necrotizing Fasciitis of the Periorbital Region Complicated by Combined Central Retinal Artery Occlusion, Central Retinal Vein Occlusion, and Posterior Ciliary Occlusion. Ophthalmic Plast Reconstr Surg. 2017 May/Jun;33(3):e75-e76. doi: 10.1097/IOP.0000000000000770. PubMed PMID: 27556345.
3)

Elkordy AM, Sato K, Inoue Y, Mano Y, Matsumoto Y, Takahashi A, Tominaga T. Central Retinal Artery Occlusion after the Endovascular Treatment of Unruptured Ophthalmic Artery Aneurysm: A Case Report and a Literature Review. NMC Case Rep J. 2016 May 19;3(3):71-74. doi: 10.2176/nmccrj.cr.2015-0243. eCollection 2016 Jul. PubMed PMID: 28664002; PubMed Central PMCID: PMC5386170.

Anterior Communicating Artery Aneurysm Risk Factors

Anterior Communicating Artery Aneurysm Risk Factors

Age, hypertension, heart disease, diabetes mellitus, cerebral atherosclerosis, aneurysms located at the internal carotid artery (ICA) and aneurysm neck width (N) correlated negatively with rupture risk. Aneurysms located at the anterior communicating artery, bifurcation, irregularity, with a daughter sac, aneurysm height, maximum size, aspect ratio (AR), height-to-width ratio and bottleneck factor were significantly and positively correlated with rupture risk 1).

The anterior communicating artery (AcomA) junction is the most common location for cerebral aneurysms. This might because of increased vascular wall shear stress due to the complex structure of the junction. The aim of a study of İdil Soylu et al. was to investigate the effect of morphological parameters in the development of anterior Communicating Artery Aneurysms. This retrospective study was approved by the institutional ethics committee. A retrospective analysis of the hospital database was performed to identify patients with AcomA aneurysms. Patients with normal computed tomography angiography (CTA) examinations were enrolled in the study as the control group. The control group was similar to the patient group in gender and age. Morphological parameters (vessel diameters, vessel diameter ratios, and vessel angles) on the same side (ipsilateral) and on the opposite side (contralateral) of the patients with aneurysm, and morphological parameters of the control group were compared. A total of 171 subjects were involved in the study (86 patients with aneurysms and 85 patients in the control group). Multivariate regression analysis revealed that the ipsilateral A1-A2 angle (OR: 0.932; 95% CI: 0.903-0.961; p < 0.001), the ipsilateral A1/A2 vessel diameter ratio (OR: 27.725; 95% CI: 1.715-448.139; p = 0.019), and the contralateral internal carotid artery (ICA)/A1 ratio (OR: 11.817; 95% CI: 2.617-53.355; p = 0.001) were significant morphological predictors for developing an aneurysm. An increased contralateral ICA/A1 ratio, an increased ipsilateral A1/A2 vessel diameter ratio, and a narrow bifurcation angle are significant predictors for developing an aneurysm. Therefore, in patients with clinical risk factors these parameters may be interpreted as additional morphological risk factors for developing an aneurysm 2).


An asymmetry of the A1 segment of the anterior cerebral artery is an assumed risk factor for the development of anterior communicating artery aneurysms (ACoAAs).

In clinic, it’s very common to find out the unequal development of section A1 of anteromedial brain artery. The resulting hemodynamic changes are considered to be one of the main reasons for the formation of anterior communicating artery aneurysms 3).

An asymmetry of the A1 segment of the anterior cerebral artery (A1SA) was identified on digital subtraction angiography studies from 127 patients (21.4%) and was strongly associated with ACoAA (p < 0.0001, OR 13.7). An A1SA independently correlated with the occurrence of ACA infarction in patients with ACoAA (p = 0.047) and in those without an ACoAA (p = 0.015). Among patients undergoing ACoAA coiling, A1SA was independently associated with the severity of ACA infarction (p = 0.023) and unfavorable functional outcome (p = 0.045, OR = 2.4).

An A1SA is a common anatomical variation in SAH patients and is strongly associated with ACoAA. Moreover, the presence of A1SA independently increases the likelihood of ACA infarction. In SAH patients undergoing ACoAA coiling, A1SA carries the risk for severe ACA infarction and thus an unfavorable outcome. Clinical trial registration no.: DRKS00005486 (http://www.drks.de/) 4).


Findings in a study of Matsukawa et al. demonstrated that the anterior projection of an ACoA aneurysm may be related to rupturing. The authors would perhaps recommend treatment to patients with unruptured ACoA aneurysms that have an anterior dome projection, a bleb(s), and a size ≥ 5 mm 5)

References

1)

Wang GX, Zhang D, Wang ZP, Yang LQ, Yang H, Li W. Risk factors for ruptured intracranial aneurysms. Indian J Med Res. 2018 Jan;147(1):51-57. doi: 10.4103/ijmr.IJMR_1665_15. PubMed PMID: 29749361; PubMed Central PMCID: PMC5967217.
2)

İdil Soylu A, Ozturk M, Akan H. Can vessel diameters, diameter ratios, and vessel angles predict the development of anterior communicating artery aneurysms: A morphological analysis. J Clin Neurosci. 2019 Jul 26. pii: S0967-5868(19)30755-6. doi: 10.1016/j.jocn.2019.07.024. [Epub ahead of print] PubMed PMID: 31358430.
3)

Okamoto S, Itoh A. Craniotomy side for neck clipping of the anterior communicating aneurysm via the pterional approach. No Shinkei Geka. 2002;30:285–291.
4)

Jabbarli R, Reinhard M, Roelz R, Kaier K, Weyerbrock A, Taschner C, Scheiwe C, Shah M. Clinical relevance of anterior cerebral artery asymmetry in aneurysmal subarachnoid hemorrhage. J Neurosurg. 2017 Nov;127(5):1070-1076. doi: 10.3171/2016.9.JNS161706. Epub 2016 Dec 23. PubMed PMID: 28009232.
5)

Matsukawa H, Uemura A, Fujii M, Kamo M, Takahashi O, Sumiyoshi S. Morphological and clinical risk factors for the rupture of anterior communicating artery aneurysms. J Neurosurg. 2013 May;118(5):978-83. doi: 10.3171/2012.11.JNS121210. Epub 2012 Dec 14. PubMed PMID: 23240701.

Giant middle cerebral artery aneurysm

Giant middle cerebral artery aneurysm

Giant middle cerebral artery aneurysm (size > 2.5 cm)

Case reports

Bendok et al. presented the case of a 61-year-old female who was brought to the emergency room after she had partial complex seizures. CT and MRI of the brain revealed a right temporal lobe mass which was initially thought to be a tumor. The patient was therefore referred to us for further management. The round nature of the lesion raised suspicion for an aneurysm. A CT angiography was performed followed by a diagnostic conventional cerebral angiogram and confirmed the presence of a giant thrombosed aneurysm 1).


A video case illustrates key surgical steps required in safe management of a giant recurrent previously coiled MCA aneurysm. The patient described in this case was a 68-year old male who presented with a sudden onset severe headache and dizziness. The patient had a history of a prior coil embolization of a 12 mm left middle cerebral artery aneurysm at an outside hospital. Imaging demonstrated recurrence of now a giant left middle cerebral artery aneurysm with coil compaction and left temporal lobe edema. MRI further demonstrated thrombus in the aneurysm and aneurysm wall enhancement concerning for impending rupture. Given the aneurysm size, imaging features and mass effect, the aneurysm was treated with microsurgical clipping. This case is valuable to the literature with a clear video case illustration of aneurysm dome excision, aneurysm endarterectomy and picket fence aneurysm neck reconstruction. Aneurysm dome excision is critical for treatment of giant aneurysms causing mass effect and was only used in this case as thrombus and coil mass did not allow for direct clipping across the neck without compromise of the MCA M2 branch. Hence, this video highlights key technical tenets, such as safe thrombus removal and adequate cleaning of the endoluminal surface and preparedness for bypass in challenging cases 2).


A 64-year-old woman who suffered subarachnoid hemorrhage in 2005. She was treated with coiling of the aneurysm at an outside institution. She presented to the clinic with headaches and was found on angiography to have giant recurrence of the aneurysm. To allow adequate exposure for clipping, Arko et al. performed the surgery through a cranio-orbito-zygomatic (COZ) skull base approach, which is demonstrated. The surgery was performed in an operating room/angiography hybrid suite allowing for high quality intraoperative angiography. The technique and room flow are also demonstrated. The video can be found here: http://youtu.be/eePcyOMi85M 3).

Videos

Left pterional craniotomy for thrombectomy and clipping of ruptured left MCA giant aneurysm

Cranio-orbito-zygomatic approach of a giant MCA aneurysm in a hybrid angio/OR suite

References

1)

Bendok BR, Abi-Aad KR, Rahme R, Turcotte EL, Welz ME, Patra DP, Hess R, Kalen B, Krishna C, Batjer HH. Tulip Giant Aneurysm Amputation and “Shingle Clip Cut Clip” Technique for Microsurgical Reconstruction of a Giant Thrombosed Middle Cerebral Artery Aneurysm. World Neurosurg. 2019 Aug 2. pii: S1878-8750(19)32108-4. doi: 10.1016/j.wneu.2019.07.192. [Epub ahead of print] PubMed PMID: 31377441.
2)

Glauser G, Piazza M, Choudhri O. Aneurysm Dome Excision and Picket Fence Clip Reconstruction of a Previously Coiled Recurrent Giant MCA Aneurysm: Technical Nuances. World Neurosurg. 2019 Apr 1. pii: S1878-8750(19)30913-1. doi: 10.1016/j.wneu.2019.03.233. [Epub ahead of print] PubMed PMID: 30947002.
3)

Arko L, Quach E, Sukul V, Desai A, Gassie K, Erkmen K. Cranio-orbito-zygomatic approach for a previously coiled/recurrent giant MCA aneurysm in a hybrid angio/OR suite. Neurosurg Focus. 2015 Jul;39(VideoSuppl1):V8. PubMed PMID: 26132625.
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