Neuro-ophthalmic effects of stenting across the ophthalmic artery origin in the treatment of intracranial aneurysms

Abstract

Object The benefits of treating intracranial aneurysms in the region of the anterior visual pathways are well understood. However, the adverse effects of endovascular stenting across the ophthalmic artery have received little attention. The authors reviewed their experience with patients who had stents deployed across the ophthalmic artery origin. Methods Patients' medical charts and imaging studies were reviewed to identify all patients with a non–flow diverting stent deployed over the ophthalmic artery origin for the treatment of intracranial aneurysms. All patients with neuro-ophthalmic complaints were referred for formal ophthalmological evaluation. Results A total of 104 consecutive patients with 106 aneurysms were identified to meet criteria for inclusion in the study cohort. Preoperatively, 30 patients (29%) described headache symptoms and 32 patients (31%) reported visual complaints. Of the patients with preoperative headaches, 15 (54%) of 28 patients for whom follow-up was available experienced improvement in their symptoms. Of the patients with preoperative visual complaints, improvement was noted in 11 (41%) of the 27 patients for whom follow-up was available, 9 (33%) of 27 patients reported no change in visual symptoms, and 7 (26%) of 27 patients reported progression of symptoms. Visual field defects developing posttreatment were noted to occur in 8 (7.7%) of 104 patients: 3 with immediate postoperative retinal infarcts, 1 with perioperative hemianopia that resolved by the time of discharge, 1 with a subjective visual field defect, 1 with subjective migratory visual field defects, and 2 with nonspecific visual symptoms. Compressive symptoms from aneurysm mass effect were noted in 6 patients preoperatively, with 4 of those patients experiencing persistent worsening, resolution in 1 case, and no change in 1 case. One patient developed a novel cranial nerve palsy from mass effect in the immediate postoperative period. Conclusions Deployment of stents across the ophthalmic artery origin for the treatment of intracranial aneurysms appears to be relatively safe with regard to visual outcomes. Neuro-ophthalmic complaint resolution rates were comparable to endovascular procedures that do not employ stents, with headache resolution rates comparable to coil-only aneurysm obliteration and low rates of retinal ischemic events. For patients presenting with mass effect, stent-assisted coiling appears to be less effective than microsurgery with decompression for relief of compressive symptoms.

Visual complications after coil embolization of internal carotid artery aneurysms at the ophthalmic segment

“…One possibility is that micro-emboli could have migrated into the OphA. 3,8,12,13,16,17,[19][20][21]27 In some of our cases, visual complications appeared from several days to several months after treatment. This may be due to the possibility that thrombotic material, which was produced in the aneurysm, migrated to the OphA.…”

“…26 Visual complications appeared in more than half of the cases within 24 h after the procedure. 20 In 22% of the patients with complications, no symptoms were present immediately after the procedure, and visual complications occurred after 24 h. Because consciousness immediately after the operation is not completely clear due to the influence of general anesthesia, we may not be aware of the visual complication immediately, and its detection may be delayed. In the cases when a deficit was confirmed within 30 min after the procedure, RAO may have already occurred during the procedure.…”

“…RAO is caused by micro-emboli migrating through the OphA to the CRA. 8,12,13,[16][17][18][19][20][21] Therefore, in the Dome and Shared types, micro-emboli from the aneurysm may easily migrate to the retinal artery. Yu et al 10 also reported that OphA origin incorporation by the aneurysm creates independent risk factors.…”

Surgical clipping is still a good choice for the treatment of paraclinoid aneurysms

“…Procedure-related complications may be observed in 10% of patients, visual complications in 8% and the recurrence rate may be up to 20% during follow-up 1,2,3,4,5,20,21,22,23,24,25,26 . Some authors propose endovascular treatment as an effective mean for small paraclinoid aneurysms (≤ 10 mm) with a low rate of recurrence.…”

“…On the other hand, some complications are described but poorly understood, such as post-procedure aneurismal bleeding and occlusion of the ophthalmic artery at its origin, which may produce undesirable outcomes 1,19,20,21,22,23,24,25,26 . In a study by Zanaty et al 30 , forty-one patients harboring 44 paraclinoid aneurysms were treated by flow-diversion.…”