Ophthalmic Artery Aneurysm: Flow-Induced Intracranial and Intraorbital (“Peripheral”) Ophthalmic Artery Aneurysms, Associated with a Tentorial Dural Arteriovenous Fistula, Supplied by the Ophthalmic Artery; Endovascular Treatment of the Dural Arteriovenous Fistula and One Aneurysm; and Conservative Management of the Remaining Ophthalmic Artery Aneurysms

Abstract

A 77-year-old male patient was admitted with a spontaneous ventricular hemorrhage, graded as Hunt and Hess III. DSA revealed a right-sided tentorial dural arteriovenous fistula (dAVF) with a large varix of a draining vein as the source of this ventricular hemorrhage. The deep recurrent meningeal artery of the right ophthalmic artery (OA) was, among other dural arteries, supplying the dAVF. Three aneurysms were found on the OA: one located in the intracranial OA segment, one in the intraorbital OA segment, and one in the deep recurrent meningeal artery. The dAVF was obliterated endovascularly. During the first treatment session, the right deep recurrent meningeal artery was catheterized from the OA, and the supply to the tentorial dAVF was interrupted by the injection of 0.3 ml Glubran 2/Lipiodol (Guerbet) in a 1:2 dilution. The deep recurrent meningeal artery aneurysm was obliterated, while the intracranial and the intraorbital aneurysms remained untreated. In a second treatment session, a retrograde transvenous approach via the basal vein of Rosenthal was chosen. The segment of this vein adjacent to the dAVF was obliterated by the injection of PHIL 25 (MicroVention) and Onyx 18 (Medtronic). Both procedures were well-tolerated, and the patient recovered from the ventricular hemorrhage. The ophthalmological examination 4 weeks after the hemorrhage and endovascular treatment showed only mild exophthalmos and paresis of the sixth cranial nerve. The management of flow-induced intraorbital OA aneurysms is the main topic of this chapter.