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Computed tomographic angiogram of an anterior communicating artery aneurysm causing acute retrobulbar optic neuropathy: a case report.
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MedLine Citation:
PMID:  21976949     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
Three-dimensional computed tomographic (3D-CT) angiography is a widespread imaging modality for intracranial vascular lesions. However, 3D-CT angiograms of an anterior communicating artery aneurysm associated with acute retrobulbar optic neuropathy have not been previously described. We present 3D-CT angiograms of an aneurysm of the anterior communicating artery that caused subarachnoid hemorrhage and vision loss in a 39-year old man. The 3D-CT angiograms were consistent with findings identified directly during surgery.
Authors:
Jee Ho Chang; Dong-Kyu Lee; Bum Tae Kim; Young-Hoon Ohn
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Publication Detail:
Type:  Case Reports; Journal Article     Date:  2011-09-20
Journal Detail:
Title:  Korean journal of ophthalmology : KJO     Volume:  25     ISSN:  1011-8942     ISO Abbreviation:  Korean J Ophthalmol     Publication Date:  2011 Oct 
Date Detail:
Created Date:  2011-10-06     Completed Date:  2012-02-02     Revised Date:  2013-06-27    
Medline Journal Info:
Nlm Unique ID:  8804513     Medline TA:  Korean J Ophthalmol     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  366-8     Citation Subset:  IM    
Affiliation:
Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
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MeSH Terms
Descriptor/Qualifier:
Acute Disease
Adult
Cerebral Angiography / methods*
Diagnosis, Differential
Follow-Up Studies
Humans
Imaging, Three-Dimensional*
Intracranial Aneurysm / complications,  radiography*
Male
Optic Nerve Diseases / etiology,  radiography*
Tomography, X-Ray Computed / methods*
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Korean J Ophthalmol
Journal ID (publisher-id): KJO
ISSN: 1011-8942
ISSN: 2092-9382
Publisher: The Korean Ophthalmological Society
Article Information
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© 2011 The Korean Ophthalmological Society
open-access:
Received Day: 30 Month: 1 Year: 2009
Accepted Day: 08 Month: 6 Year: 2010
Print publication date: Month: 10 Year: 2011
Electronic publication date: Day: 20 Month: 9 Year: 2011
Volume: 25 Issue: 5
First Page: 366 Last Page: 368
ID: 3178776
PubMed Id: 21976949
DOI: 10.3341/kjo.2011.25.5.366

Computed Tomographic Angiogram of an Anterior Communicating Artery Aneurysm Causing Acute Retrobulbar Optic Neuropathy: A Case Report
Jee Ho Chang1
Dong-Kyu Lee1
Bum Tae Kim2
Young-Hoon Ohn1
1Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
2Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
Correspondence: Reprint requests to Young-Hoon Ohn, MD, PhD. Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, #1174 Jung-dong, Wonmi-gu, Bucheon 420-767, Korea. Tel: 82-32-621-5053, Fax: 82-32-621-5433, yhohn@schbc.ac.kr

Three-dimensional computed tomographic (3D-CT) angiography has recently gained popularity for diagnosing intracranial vascular disease [1]. However, to our knowledge 3D-CT angiographic images of an anterior communicating artery aneurysm associated with acute retrobulbar optic neuropathy have never been reported. Here, we report a case of a ruptured anterior communicating artery aneurysm causing acute retrobulbar optic neuropathy that was examined by 3D-CT angiography.


Case Report

A 39-year-old man presented to the emergency department of Soonchunhyang University Bucheon Hospital with disorientation and severe headache. Brain CT scans demonstrated subarachnoid hemorrhage. 3D-CT angiography of the brain (Somatom Sensation 16; Siemens, Forchheim, Germany) revealed a large aneurysm arising from the junction of the right anterior cerebral and the anterior communicating arteries that was oriented downward (Fig. 1A-1C). This finding prompted emergent neurosurgical intervention, during which the aneurysmal neck was clipped successfully (Fig. 1D). On the fifth postoperative day, the patient's mental status had improved and he complained of right eye vision loss. On ophthalmologic examination, the patient's visual acuity was no light perception (NLP) OD and 1.0 OS and his right pupil was nonresponsive. In retrospect, the patient recalled noticing a visual field defect encroaching from the inferior field in the right eye 10 days before admission, but he thought it was a manifestation of headache. The results of external, motility, and slit lamp examinations were all normal. The results of dilated fundus examinations were normal in both eyes, and the optic nerves in particular appeared normal. After three months, the vision in the patient's right eye remained NLP, and atrophy of the right optic nerve had occurred.


Discussion

With recent advances of CT and magnetic resonance imaging, the diagnosis and treatment of cerebrovascular disease have become more accurate and effective. Acute retrobulbar optic neuropathy due to an anterior communicating artery aneurysm is rare, and to our knowledge 3D-CT angiographic images of this condition have never been reported.

Although sudden unilateral visual loss combined with signs of retrobulbar optic nerve dysfunction suggests a diagnosis of optic neuritis, especially when associated with normal looking discs, vascular and compressive lesions may be considered in certain cases. Diagnosis was straightforward in the present case. The patient presented with altered mental status and headache. Conventional CT revealed vascular pathology, and the choice of advanced vascular imaging modality was left to the physician. Although conventional digital subtraction angiography (DSA) is considered the most sensitive tool for detection of intracranial aneurysms, we did not perform DSA because it is an invasive study. Furthermore, considering the potential delays in time required to assemble the angiography team and perform the angiogram, CT angiography is often faster and is comparably accurate [2]. Magnetic resonance angiogram is another option, and it has advantages for the evaluation of cerebrovascular lesions. However, in our case, CT angiography was perceived to be faster and less likely to induce claustrophobia [3].

The choice of treatment modality is also worthy of discussion. Although endosaccular occlusion of the intracranial aneurysm was considered in the present case, urgent decompression of the aneurysm could not be achieved by this treatment because of the volume effect of the coils. In our patient, immediate decompression was mandatory and emergent surgical decompression with clipping of the aneurysm was identified as the treatment most likely to rescue vision [4].

Unfortunately, despite successful surgical decompression, the patient's vision did not recover. There are several explanations for monocular visual loss due to a ruptured anterior communicating artery aneurysm, including direct bleeding into the optic nerve, direct compression by the aneurysm [5], and interruptions of blood flow to arteries supplying posterior portions of the optic nerve as a result of either the subarachnoid hemorrhage itself, subsequent vasospasm, or the surgical clipping of the aneurysm [6]. The previous recognition of an inferior visual field defect 10 days before the attack suggests that direct compression of the optic nerve by the aneurysm was contributory.


Notes

No potential conflict of interest relevant to this article was reported.

Acknowledgements

We thank Dr. Nancy J. Newman (Director, Section of Neuro-Ophthalmology, Department of Ophthalmology, Emory University, Atlanta, GA, USA) for her critical review and proofreading of this manuscript.


References
1. Lovblad KO,Altrichter S,Viallon M,et al. Neuro-imaging of cerebral ischemic strokeJ NeuroradiolYear: 20083519720918329713
2. Alberico RA,Patel M,Casey S,et al. Evaluation of the circle of Willis with three-dimensional CT angiography in patients with suspected intracranial aneurysmsAJNR Am J NeuroradiolYear: 199516157115787502958
3. Thijs V. Imaging techniques for acute ischemic stroke: nice gadgets or essential tools for effective treatment?NeuroradiologyYear: 20105216917120016884
4. Craenen G,Brown SM,Freedman KA,et al. Rapid, painless unilateral vision loss in a 37-year-old healthy womanSurv OphthalmolYear: 20044934334815110670
5. Chan JW,Hoyt WF,Ellis WG,Gress D. Pathogenesis of acute monocular blindness from leaking anterior communicating artery aneurysms: report of six casesNeurologyYear: 1997486806839065547
6. Hara N,Mukuno K,Ohtaka H,Shimizu K. Ischemic optic neuropathy associated with subarachnoid hemorrhage after rupture of anterior communicating artery aneurysmOphthalmologicaYear: 2003217798412566879

Article Categories:
  • Case Report

Keywords: Intracranial aneurysm, Retrobulbar optic neuropathy, Three-dimensional computed tomographic angiogram.

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