Ophthalmic Artery Pseudoaneurysm
Article summary goes here.
Disease Entity
Ophthalmic artery pseudoaneurysm is a rare condition characterized by the formation of a false aneurysm in the ophthalmic artery. This can result from trauma, injury, infection, or certain medical procedures.
Etiology
In contrast to a true aneurysm, a pseudoaneurysm is not contained by the vessel wall; instead, blood leaking through a defect in the arterial wall is contained by an out-pouching of adventitia or perivascular soft tissue.[1] The most common cause of ophthalmic artery pseudoaneurysm (OAPA) is trauma, such as blunt or penetrating trauma to the eye or head, but it can also be caused by inflammation, infection, or other underlying medical conditions.
Diagnosis
The diagnosis of ophthalmic artery pseudoaneurysm (OAPA) typically involves a combination of clinical evaluation, detailed eye exams, radiological imaging studies, and additional interventional studies useful in characterizing the pseudoaneurysm.
CT Head, CT angiogram
These are useful imaging modalities for initial screenings for patients suspecting of OAPA. Since pseudoaneurysm tends to develop in the setting of traumatic injury, when patient first presented to the emergency, the CT head without contrast is almost always ordered by the emergency department. It would also be useful to include CT angiogram of the head and the neck. This would not only help to narrow down other possible causes of traumatic injuries, but also help to localize the site of the lesion to establish an imaging baseline.
History
The history-taking portion should focus on any recent facial and ocular injuries or surgeries. These include fist fight, traffic accidents (whiplash injuries, etc.), fall, or any other high-energy impact trauma. Other risk factors, such as prior history of ocular infection, cellulitis, arterial-venous fistulas, and any other significant orbital histories are also useful. Comorbidities such as diabetes and cardiovascular disease are also important as patients might be taking anti-platelets or antithrombotic medications which could greatly increase the risk of pseudoaneurysm malformation.
Physical examination
A thorough physical examination of the eye and surrounding structures should be conducted to assess visual acuity, ocular motility, and clinical signs of inflammation, swelling, proptosis, or pulsatile mass around the orbit.
Diagnostic procedures
Studies in the literature have reported using various imaging techniques such as CT, MRI, or digital subtraction angiography to identify these lesions.[2][3] Digital subtraction angiography seems to be the diagnostic modality of choice for these lesions.[4]
Management
Surgery
Prompt endovascular occlusion can prevent complications such as enlargement, hemorrhage, and hematoma formation.[5] This can be achieved by microcatheterization and coil embolization.[6] In this procedure an endovascular wire is navigated to the pseudoaneurysm, followed by a microcatheter which is then used to deliver the coil for embolization. Angiography is then used to confirm a complete coil embolization. If the proximal ophthalmic artery becomes occluded, branches of the external carotid artery provide collateral bloodflow to the visual system through anastomoses with the extraorbital branches of the ophthalmic artery.[3]
One study reported a case of OAPA presenting with persistent epistaxis after removal of a nasogastric tube.[4] This patient was treated with 25% NBCA injection to embolize the lesion.
Conservative management
At this time there have been one recorded conservative management case in approaching OAPA, which is done at Umass Memorial Hospital
Prognosis
OAPAs are dangerous because they can enlarge over time and eventually rupture, resulting in intracranial hemorrhage or hematoma formation.[5] Pseudoaneurysm of the dural portion of the ophthalmic artery can result in subarachnoid hemorrhage with a high risk of re-hemorrhage if left untreated.[6]
References
- ↑ Patil NS, Kumar AH, Pamecha V, et al. Cystic artery pseudoaneurysm-a rare complication of acute cholecystitis: review of literature. Surg Endosc. Feb 2022;36(2):871-880. doi:10.1007/s00464-021-08796-1
- ↑ Czyz CN, Piehota PG, Strand AT, Stein M. Post-traumatic ophthalmic artery pseudoaneurysm from orbital projectile. Can J Ophthalmol. Aug 2017;52(4):e130-e132. doi:10.1016/j.jcjo.2016.12.007
- ↑ 3.0 3.1 Hopkins JK, Shaibani A, Ali S, et al. Coil embolization of posttraumatic pseudoaneurysm of the ophthalmic artery causing subarachnoid hemorrhage. Case report. J Neurosurg. Nov 2007;107(5):1043-6. doi:10.3171/JNS-07/11/1043
- ↑ 4.0 4.1 Selcuk H, Soylu N, Albayram S, et al. Endovascular treatment of persistent epistaxis due to pseudoaneurysm formation of the ophthalmic artery secondary to nasogastric tube. Cardiovasc Intervent Radiol. 2005;28(2):242-5. doi:10.1007/pl00021048
- ↑ 5.0 5.1 Chun HJ, Yi HJ. Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: case report. Surg Neurol. Jun 2009;71(6):701-4. doi:10.1016/j.surneu.2007.11.018
- ↑ 6.0 6.1 Kelly ME, Fiorella D. Traumatic ophthalmic artery pseudoaneurysm coiled with a steerable microcatheter. Can J Neurol Sci. Jul 2009;36(4):496-9. doi:10.1017/s0317167100007861
