Objective: To review the rate of carotid-ophthalmic aneurysm (COA) rupture and to identify protective features that may contribute to their low rupture rate.
Methods: We reviewed the records of 790 patients with 773 aneurysms greater than 2 mm treated by endovascular routes between 2002 and 2012 at our institution. Seventy five carotid-ophthalmic aneurysms were identified in 72 patients. Three injected human cadaver heads were studied to evaluate the perianeurysmal environment of the carotid-ophthalmic region.
Results: Only 2 (2.8%) of these 72 patients presented with acute SAH due to a ruptured carotid-ophthalmic aneurysm. The average size of ruptured COA was 11.3 mm versus 7 mm for unruptured aneurysms. Most of the aneurysms were discovered in patients who were asymptomatic. The most common presenting symptom was headache. In this study, we also provide cadaveric anatomic illustrations of the perianeurysmal environment in order to investigate the low rate of COA rupture. Additionally, we highlight the existence of a double arachnoid layer consisting of the arachnoid on the inferior aspect of the optic nerve and surrounding the internal carotid artery (ICA), which could further contribute to the low rupture rate of these aneurysms.
Conclusions: Carotid-ophthalmic aneurysms are uncommon sources of subarachnoid hemorrhage. The perianeurysmal environment surrounding these aneurysms may provide protection, lending these aneurysms to a relatively benign natural history.
1. Beck J, Rohde S, el Beltagy M, Zimmermann M, Berkefeld J, Seifert V, et al: Difference in configuration of ruptured and unruptured intracranial aneurysms determined by biplanar digital subtraction angiography. Acta neurochirurgica 145:861-865; discussion 865, 2003
2. Brilstra EH, Rinkel GJ, van der Graaf Y, van Rooij WJ, Algra A: Treatment of intracranial aneurysms by embolization with coils: a systematic review. Stroke; a journal of cerebral circulation 30:470-476, 1999
3. Fulkerson DH, Horner TG, Payner TD, Leipzig TJ, Scott JA, DeNardo AJ, et al: Results, outcomes, and follow-up of remnants in the treatment of ophthalmic aneurysms: a 16-year experience of a combined neurosurgical and endovascular team. Neurosurgery 64:218-229; discussion 229-230, 2009
4. Gibo H, Lenkey C, Rhoton AL, Jr.: Microsurgical anatomy of the supraclinoid portion of the internal carotid artery. Journal of neurosurgery 55:560-574, 1981
5. Henkes H, Fischer S, Weber W, Miloslavski E, Felber S, Brew S, et al: Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results. Neurosurgery 54:268-280; discussion 280-265, 2004
6. Horiuchi T, Tanaka Y, Kusano Y, Yako T, Sasaki T, Hongo K: Relationship between the ophthalmic artery and the dural ring of the internal carotid artery. Clinical article. Journal of neurosurgery 111:119-123, 2009
7. Im SH, Han MH, Kwon OK, Kwon BJ, Kim SH, Kim JE, et al: Endovascular coil embolization of 435 small asymptomatic unruptured intracranial aneurysms: procedural morbidity and patient outcome. AJNR. American journal of neuroradiology 30:79-84, 2009
8. Inagawa T, Hirano A: Autopsy study of unruptured incidental intracranial aneurysms. Surgical neurology 34:361-365, 1990
9. Kondo S, Hashimoto N, Kikuchi H, Hazama F, Nagata I, Kataoka H: Cerebral aneurysms arising at nonbranching sites. An experimental Study. Stroke; a journal of cerebral circulation 28:398-403; discussion 403-394, 1997
10. Lanterna LA, Tredici G, Dimitrov BD, Biroli F: Treatment of unruptured cerebral aneurysms by embolization with guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding--a systematic review of the literature. Neurosurgery 55:767-775; discussion 775-768, 2004
11. Levy E, Koebbe CJ, Horowitz MB, Jungreis CA, Pride GL, Dutton K, et al: Rupture of intracranial aneurysms during endovascular coiling: management and outcomes. Neurosurgery 49:807-811; discussion 811-803, 2001
12. Longstreth WT, Jr., Koepsell TD, Yerby MS, van Belle G: Risk factors for subarachnoid hemorrhage. Stroke; a journal of cerebral circulation 16:377-385, 1985
13. Loumiotis I, D'Urso PI, Tawk R, Cloft HJ, Kallmes DF, Kairouz V, et al: Endovascular treatment of ruptured paraclinoid aneurysms: results, complications, and follow-up. AJNR. American journal of neuroradiology 33:632-637, 2012
14. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267-1274, 2002
15. Naggara ON, White PM, Guilbert F, Roy D, Weill A, Raymond J: Endovascular treatment of intracranial unruptured aneurysms: systematic review and metaanalysis of the literature on safety and efficacy. Radiology 256:887-897, 2010
16. Nguyen TN, Raymond J, Guilbert F, Roy D, Berube MD, Mahmoud M, et al: Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture. Journal of neurosurgery 108:1088-1092, 2008
17. Park HK, Horowitz M, Jungreis C, Kassam A, Koebbe C, Genevro J, et al: Endovascular treatment of paraclinoid aneurysms: experience with 73 patients. Neurosurgery 53:14-23; discussion 24, 2003
18. Qureshi AI, Luft AR, Sharma M, Guterman LR, Hopkins LN: Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: Part I--Pathophysiological and pharmacological features. Neurosurgery 46:1344-1359, 2000
19. San Millan Ruiz D, Yilmaz H, Dehdashti AR, Alimenti A, de Tribolet N, Rufenacht DA: The perianeurysmal environment: influence on saccular aneurysm shape and rupture. AJNR. American journal of neuroradiology 27:504-512, 2006
20. Seshaiyer P, Humphrey JD: On the potentially protective role of contact constraints on saccular aneurysms. Journal of biomechanics 34:607-612, 2001
21. Sforza DM, Putman CM, Cebral JR: Hemodynamics of Cerebral Aneurysms. Annual review of fluid mechanics 41:91-107, 2009
22. Sherif C, Gruber A, Dorfer C, Bavinzski G, Standhardt H, Knosp E: Ruptured carotid artery aneurysms of the ophthalmic (C6) segment: clinical and angiographic long term follow-up of a multidisciplinary management strategy. Journal of neurology, neurosurgery, and psychiatry 80:1261-1267, 2009
23. Vernooij MW, Ikram MA, Tanghe HL, Vincent AJ, Hofman A, Krestin GP, et al: Incidental findings on brain MRI in the general population. The New England journal of medicine 357:1821-1828, 2007
24. Wardlaw JM, White PM: The detection and management of unruptured intracranial aneurysms. Brain : a journal of neurology 123 (Pt 2):205-221, 2000
25. Wiebers DO, Whisnant JP, Huston J, 3rd, Meissner I, Brown RD, Jr., Piepgras DG, et al: Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103-110, 2003