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.

Predictors of Peri-Ophthalmic Aneurysm Incomplete Occlusion and Visual Symptoms After Treatment with a Pipeline Embolization Device: A Multi-Center Cohort Study

Objective: Peri-ophthalmic aneurysm is a special type of aneurysm. We assessed the relationship between ophthalmic artery (OA) origin and aneurysm and examined the effect of a pipeline embolization device (PED, Covidien/Medtronic) with or without coils on aneurysm occlusion rate and visual outcomes.Methods: We retrospectively analyzed 194 peri-ophthalmic aneurysms in 189 patients among 1,171 patients treated with a PED in a Chinese post-market multi-center registry study from November 2014 to October 2019. Peri-ophthalmic aneurysms were defined as carotid–ophthalmic segment aneurysms arising from the internal carotid artery dorsal wall at, or distal to, the OA origin, with a superior or superomedial projection. The relationship between OA origin and the aneurysm was classified as follows: Type A, OA originating separate from the aneurysm; Type B, OA originating from the aneurysm neck or dome. Patients with aneurysm were divided into the PED-only group and the PED + coils group according to treatment. Results: The median follow-up time was 6.8 months (range, 5.3–20.2 months). There were 163 occluded aneurysms (84%) and 31 aneurysms with incomplete occlusion (16%). A multivariate analysis showed that Type B aneurysm was a risk factor for incomplete occlusion in the PED-only group (odds ratio [OR] 4.951, 95% confidence interval [CI] 1.904-12.875, p = 0.001). Visual symptoms at final follow up correlated with preoperative visual symptoms (OR 16.005, 95% CI 2.505-102.273, p = 0.003).Conclusions: Type B aneurysm is associated with a lower occlusion rate after PED-only treatment. Patients with preoperative visual symptoms should be treated promptly to avoid permanent visual symptoms.

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

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.

Balloon-Assisted Coils Embolization for Ophthalmic Segment Aneurysms of the Internal Carotid Artery

Objective: To explore the role of balloon-assisted coils technique for ophthalmic segment aneurysms (OSAS).Methods: Clinical data of 30 patients with OSAS were reviewed between December 2017 and December 2018. OSAS were defined as arising from the internal carotid artery (ICA), reaching from the distal dural ring to the origin of the posterior communicating artery. OSAS were classified into four types based on the angiographic findings. The balloon-assisted coils technique was used for the embolization of aneurysms. The duration of balloon inflation cycles, as well as difficulty and complications during the embolization procedure, were recorded. The immediate angiographic results were evaluated according to the Raymond scale. Clinical results were evaluated based on the MRS score. Follow-ups were performed at 18 months post-embolization by DSA or MRA at our institution.Results: Thirty-two aneurysms in 30 patients were detected by digital subtraction angiography (DSA), which included 30 unruptured and two ruptured cases. The patients with ruptured aneurysms were grade II status according to the Hunt-Hess scale. Three cases were type A, nine cases were type B, 17 cases were type C, and three cases were type D. According to aneurysm size, there were 19 cases of small, 11 cases of medium, two cases of large aneurysm. Thirty-two aneurysms were successfully embolized in 30 patients by balloon-assisted coils technique. The ophthalmic artery could be protected by an engorged balloon in the procedure, especially for type A aneurysms. Considering that type D aneurysm arises from the side-wall of the artery and near to tortuous ICA siphon, the balloon catheter was inflated to stabilize the microcatheter allowing for overinflation when necessary. The average duration of balloon dilatation was 4 min, and the average time was 2.5 times. Raymond class was one in 28 aneurysms and two in four aneurysms according to the immediate post-embolization angiographic results. All the patients achieved good clinical effects, except for one patient who presented with brain ischemia resulting in dizziness and contralateral limb weakness for 10 h due to prolonged temporary clamping of the responsible ICA. The follow-up angiography results were satisfactory at 18 months post-embolization.Conclusion: OSAS endovascular treatment with balloon-assisted coils has different advantages in a different classification. The technique is safe, effective, and relatively inexpensive, especially for small and medium OSAS.

Microsurgical clipping of paraclinoid aneurysms

Background. Paraclinoid aneurysm is a nonspecific term that includes ophthalmic segment aneurysms and distal cavernous internal carotid artery (ICA) aneurysms. The literature mostly described the frequency to be in the range of 1.3-5%. and a high incidence of being multiple or having a large size. Methods. A retrospective review of 18 consecutive patients surgically treated for paraclinoid aneurysm was performed. The data of all our consecutive patients were searched to obtain patient and aneurysm characteristics, treatment details, complications and follow up. Clinical outcome was graded according to the modified Rankin scale. The follow-up period varied widely from 3 to 62 months (mean 26 months). Results. Surgical clipping was performed for 15 ruptured paraclinoid aneurysms; only in 3 cases the aneurysm was unruptured. Post-operative control angiography was performed in 10 patients (55.56%), from which we reported a full occlusion of the aneurysm in 9 patients (90%). Best results were obtained in patients who preoperatively were included in 1st and 2nd grade of Hunt & Hess scale. Two months postoperative follow-up was complete for all but one patient who died 12 days after surgery, from cerebral ischemia resulting from severe cerebral vasospasm. There were excellent and good results (mRS 0–2) in 88% of the cases (15 out of 17 patients) at two months follow-up, and 94% (16 out of 17 patients) at six months follow-up. Three patients with slight disabilities, ranked mRS 1-2 at two months follow-up, improved to mRS 0, with no symptoms at all, at 6 months postoperative control. All 3 patients with a surgically treated non-ruptured paraclinoid aneurysm had an excellent outcome (mRS 0). Conclusions. Most appropriate treatment is to occlude aneurysms without compromising patency of the parent artery. Anterior clinoidectomy and microsurgical clipping can still be a standard treatment despite of recent development of endovascular coiling procedures.