Atormac
brintellex
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 18744  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (2,261 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
   References
   Article Figures

 Article Access Statistics
    Viewed3700    
    Printed48    
    Emailed0    
    PDF Downloaded32    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 657-660

Intraorbital traumatic ophthalmic artery aneurysm: Case report


1 Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
2 Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
3 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Date of Submission23-Jun-2012
Date of Decision13-Jul-2012
Date of Acceptance26-Aug-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Ji-zong Zhao
Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105213

Rights and Permissions



How to cite this article:
Li Y, Song Wx, Zhang Tm, Fu Jd, Sun S, Zhao Jz. Intraorbital traumatic ophthalmic artery aneurysm: Case report . Neurol India 2012;60:657-60

How to cite this URL:
Li Y, Song Wx, Zhang Tm, Fu Jd, Sun S, Zhao Jz. Intraorbital traumatic ophthalmic artery aneurysm: Case report . Neurol India [serial online] 2012 [cited 2020 Aug 6];60:657-60. Available from: http://www.neurologyindia.com/text.asp?2012/60/6/657/105213


Sir,

Intraorbital segment ophthalmic artery aneurysm is an extremely rare condition, and only 17 cases have been reported in the literature till today. [1] It can be caused by traumatic, blunt or penetrating head injuries and represents fewer than 1% of all cerebral aneurysms. [2],[3] Because traumatic aneurysms are fragile and prone to rupture, early diagnosis with angiography is essential.

A 25-year-old man suffered from blunt head injury after being assaulted, and was admitted to a local hospital. He was assaulted by three men, following which he fell down, and his face was kicked with leather shoes by one of the assaulters. After this incidence, he was conscious and complained of severe headache and vomiting. Examination revealed blindness and right eye ophthalmoplegia. Brain computed tomography (CT) scan revealed diffuse subarachnoid hemorrhage (SAH) [Figure 1]. The patient was managed conservatively. One day later, he developed right exophthalmos and his condition rapidly deteriorated. He was then transferred to our hospital 5 days after injury. At admission, examination revealed an alert, oriented man with right eye blindness and luxation of the right eyeball [Figure 2]. CT scan of the orbit revealed right-sided orbital fracture and orbital apex hematoma [Figure 3]. CT angiography (CTA) revealed an intraorbital aneurysm [Figure 4]. He subsequently developed cerebral digital subtraction angiography (DSA), which demonstrated a traumatic aneurysm arising from the intraorbital segment ophthalmic artery [Figure 5]. He underwent aneurysm clipping and resection through a right cranio orbital approach under general anesthesia. The fronto temporal and superior lateral orbital rim bone flaps were performed, followed by removal of the posterior part of the orbital roof for orbital decompression. Thus, the superior orbital fissure and optic canal both were exposed. The intraorbital pressure was found to be very high. Also, after the orbital periosteum was incised, the clot in the orbital apex was evacuated, and a thrombosed traumatic aneurysm was seen bleeding. Temporary clipping of the proximal intraorbital segment ophthalmic artery was performed to stop the bleeding, followed by resection of pseudo-aneurysm [Figure 6]. The ophthalmologists relocated the right eyeball during the surgery, and the suture of palpebral fissure was performed. The postoperative course was uneventful, and the luxation of the right eyeball was relieved immediately. The patient was discharged on the 10 th postoperative day. One-month clinical follow up demonstrated blindness in the right eye and total ophthalmoplegia.
Figure 1: Noncontrast axial computed tomography scan reveals diffuse subarachnoid hemorrhage in the patient in the study

Click here to view
Figure 2: Preoperative photography shows luxation of the right eyeball in the patient in the study

Click here to view
Figure 3: Admission axial orbital computed tomography scan reveals right orbital apex hematoma in the patient in the study

Click here to view
Figure 4: Contrasted computed tomography scan reveals right intraorbital aneurysm in the patient in the study

Click here to view
Figure 5: Lateral view of right internal carotid artery angiogramreveals the aneurysm arising from the ntraorbital segment ophthalmic artery. Note the complete disappearance of distal segment of the ophthalmic artery

Click here to view
Figure 6: Intraoperative photography shows the specie of aneurysm in the patient in the study

Click here to view


The ophthalmic artery is the major blood supply of the orbit, and it arises from the internal carotid artery (ICA), which in turn emerges from the cavernous sinus. The ophthalmic artery enters the orbit through the optic canal and consists of intracranial, intracanalicular and intraorbital segments, and gives off the central retinal, ciliary, lacrimal, posterior and anterior ethmoidal artery branches. We have here reported an extremely rare case of a traumatic aneurysm of the intraorbital segment of the ophthalmic artery with luxation of the eyeball. Only 17 cases of intraorbital segment ophthalmic artery aneurysms have been reported so far in the literature, with 4 cases having an unambiguous history of head trauma. [1],[4],[5],[6],[7],[8] Traumatic aneurysms can result from a direct injury to the arterial wall or from acceleration-induced shear. These aneurysms develop within hours after trauma, the majority being pseudoaneurysms (false aneurysm). Most traumatic pseudoaneurysms are found at the skull base or on the surface of the brain, and are seen with severe head injuries. These aneurysms are characterized by the presence of organizing hematoma and fibrosis without true vascular elements. In our patient, histopathology of resected aneurysm specimen confirmed the wall of aneurysm as a clot with no true vascular elements [Figure 7]. Thus, the possible mechanism of the aneurysm formation may be the collision with the the orbital walls or shear stress to the intraorbital segment of ophthalmic artery, causing the formation of a pseudoaneurysm from the hematoma in the cavity of the orbital apex. During intra orbital bleeding, there is little room to accommodate the increase in the volume. The globe and septum are displaced anteriorly causing proptosis, and an increased pressure on the orbital structures with their resultant compression can be appreciated. This can cause acute loss in the vision by compressing the optic nerve and its vascular supply. [9],[10] The main cause of blindness in this patient was injury to the intraorbital segment of ophthalmic artery, which was also confirmed during the surgery.

We perform CTA as a non-invasive screening examination in patients with head injuries, skull base fractures and SAH. Furthermore, DSA is necessary to confirm the diagnosis of aneurysms. Endovascular therapy is an effective approach for traumatic intracranial aneurysms, and allows early aneurysm exclusion with excellent results. [3]
Figure 7: Histopathological findings of the resected specimen in the patient in the study

Click here to view


However for this patient, the cranio-orbital approach with orbital decompression was used, as it would solve the complication of severe exophthalmos simultaneously.

 
  References Top

1.Qiao L, Wang HD, Mao L, Chen SH, Xie W, Wu Q. Peripheral ophthalmic artery aneurysm. Neurosurg Rev 2011;34:29-38.  Back to cited text no. 1
    
2.Dubey A, Sung WS, Chen YY, Amato D, Mujic A, Waites P, et al. Traumatic intracranial aneurysm: A brief review. J Clin Neurosci 2008;15:609-12.  Back to cited text no. 2
[PUBMED]    
3.Cohen JE, Gomori JM, Segal R, Spivak A, Margolin E, Sviri G, et al. Results of endovascular treatment of traumatic intracranial aneurysms. Neurosurgery 2008;63:476-86.  Back to cited text no. 3
[PUBMED]    
4.Meyerson L, Lazar SJ. Intraorbital aneurysm of the ophthalmic artery. Br J Ophthamol 1971;55:199-204.  Back to cited text no. 4
[PUBMED]    
5.Rahmat H, Abbassioun K, Amirjamshidi A. Pulsating unilateral exophthalmos due to traumatic aneurysm of the intraorbital ophthalmic artery. Case report. J Neurosurg 1984;60:630-2.  Back to cited text no. 5
[PUBMED]    
6.Choi BK, Lee TH, Choi CH, Lee SW. Fusiform intracanalicular ophthalmic artery aneurysm; Case report and review of literature. J Korean Neurosurg Soc 2008;44:43-6.  Back to cited text no. 6
[PUBMED]    
7.Chun HJ, Yi HJ. Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: Case report. Surg Neurol 2008;71:701-4.  Back to cited text no. 7
[PUBMED]    
8.Sabatino G, Albanese A, Di Muro L, Marchese E. Bilateral intra-orbital ophthalmic artery aneurysms. Acta Neurochir (Wien) 2009;151:831-2.  Back to cited text no. 8
[PUBMED]    
9.Vassallo S, Hartstein M, Howard D, Stetz J. Traumatic retrobulbar hemorrhage: Emergent decompression by lateral canthotomy and cantholysis. J Emerg Med 2002;22:251-6.  Back to cited text no. 9
[PUBMED]    
10.Ernemann U, Freudenstein D, Pitz S, Naegele T. Intraorbital aneurysm of the ophthalmic artery: A rare cause of apex orbital compression syndrome. Graefes Arch Clin Exp Ophthalmol 2002;240:575-7.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

This article has been cited by
1 Intraorbital and intracanalicular ophthalmic artery aneurysms. Literature review and report of a case
Giuseppe Maria Della Pepa,Giovanni Sabatino,Giuseppea La Rocca,Alba Scerrati,Giulio Maira,Alessio Albanese,Enrico Marchese
British Journal of Neurosurgery. 2014; : 1
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow