Anatomic features of the intracranial and intracanalicular portions of ophthalmic artery: for the surgical procedures

The intracranial and intracanalicular portions of the ophthalmic artery is suspectible to various diseases and injuries; therefore, knowledge of the microanatomy of the complex bony, dural, vascular, and neural relationships of this segment is necessary for proper diagnosis and preservation of the neurovascular structures during subfrontal, pterional and intracanalicular procedures. The artery was studied in 38 human adult cadaver specimens regarding origin, intracranial and intracanalicular portions for surgical approachs. The ophthalmic artery originated from the intradural portion of the internal carotid artery, except in 5% where the ophthalmic artery originated extradurally. The ophthalmic artery originated from medial of superior wall of internal carotid artery in 73.7%, from the central in 21% and the lateral in 5.3% of the specimens. The diameter of the ophthalmic artery at its origin was 2.25±0.3 mm on the right and 2.16±0.4 mm on the left. The intracranial and intracanalicular course of the artery was divided into short limb, angle “a”, long limb, angle “b” and distal part to the apex of the orbit. Awareness of variations in anatomic structures is paramount importance both for diagnosis and treatment of vascular lesions of the brain.     

Protection of anastomotic pathways to the vertebral artery during stenting of external carotid artery stenosis

A 61-year-old man presented with a severe external carotid artery (ECA) stenosis with concomitant ipsilateral internal carotid artery (ICA) occlusion manifesting as amaurosis fugax. The left ophthalmic artery was supplied from the left ECA. The left intracranial ICA was supplied by the collateral flow from the contralateral ICA and ipsilateral ECA through the ophthalmic artery. The left vertebral artery also participated in the latter collateral pathway through the left occipital artery and ascending pharyngeal artery. Percutaneous revascularization of the ECA was performed using a nitinol self-expanding stent. To prevent embolic complications through the ophthalmic or vertebral arteries, distal protection was performed using a balloon. During a 22-month follow-up period, the patient was completely free from any ocular or neurological symptoms. The present case of severe ECA stenosis with ipsilateral ICA occlusion showed that percutaneous balloon angioplasty with stenting is feasible and effective. This intervention requires cautious evaluation of the anastomotic pathways connecting the ECA to the cerebral circulation to avoid embolic complications.     

Local intraarterial fibrinolysis in central retinal artery occlusion: case report

The authors report a case of local intraarterial fibrinolysis (LIF) in central retinal artery occlusion (CRAO). A 79-year-old man with stenosis of the left internal carotid artery (ICA) suffered sudden loss of vision in his left eye. LIF was carried out using a microcatheter in the origin of the ophthalmic artery on the side of the CRAO. Treatment was performed with 120,000 IU of urokinase. After LIF, marked improvement of vision was established. No complication occurred during LIF. One month later, carotid artery stenting was performed for the left ICA stenosis. We consider LIF in CRAO is effective treatment.     

Agenesis of the left internal carotid artery with an ophthalmic artery arising from the posterior communicating artery

A case of agenesis of left internal carotid artery is reported. The patient is a forty one-year-old house-wife with sudden episode of headache when she had a fever. CT scan of the head showed a small high density area in the right frontotemporal subcortical region. Four vessel cerebral angiography demonstrated negative lesion except for complete absence of the left internal carotid artery. The blood supply to the left cerebral hemisphere was provided both through the tortuous anterior communicating artery and through the enlarged left posterior communicating artery. Left ophthalmic artery arose from the left posterior communicating artery. The embryological developmental process of this kind of vascular anomaly as well as the relationship between intravascular hemodynamic stress and the induction of cerebral aneurysm were discussed in detail.     

Middle meningeal origin of the ophthalmic artery

OBJECTIVE: To examine the microsurgical anatomy and clinical significance of an anomalous origin of the ophthalmic artery from the middle meningeal artery. METHODS: In the course of an anatomic study of the cavernous sinus, an anomalous ophthalmic artery arising from the middle meningeal artery was found. To further define the anatomy of the region, five additional skulls, in which the arteries and veins were injected with colored latex, were dissected using 3x to 40x magnification. RESULTS: The anomalous ophthalmic artery arose from the frontal branch of the middle meningeal artery, passed through the superior orbital fissure, and supplied the entire contents of the orbit, as well as giving rise to the central retinal artery. This study provides the first display of this anomaly in an anatomic dissection. CONCLUSION: The ophthalmic artery may infrequently arise from the middle meningeal artery. This anomaly places the ophthalmic artery at risk during procedures in which the dura is elevated from the greater and lesser wings of the sphenoid or when the sphenoid ridge is removed and during embolization procedures involving the branches of the external carotid artery.     

Effect of carotid endarterectomy on the ophthalmic artery

Summary. Summary.   Background: To evaluate the effect of carotid endarterectomy on ophthalmic artery flow direction and peak systolic flow velocity, the authors examined the ophthalmic artery on 32 patients who had undergone carotid endarterectomy.   Methods: The 32 patients had more than 70% stenosis of the internal carotid artery at its origin on angiography. The ophthalmic artery ipsilateral to the carotid endarterectomy was evaluated by the ophthalmic artery color Doppler flow imaging before surgery and then at one week, one month, and three months after surgery.   Findings: (1) Before carotid endarterectomy: eight patients showed reversed ophthalmic artery direction. In the other 24 patients with antegrade ophthalmic artery flow direction, the average peak systolic flow velocity was 0.17±0.10 m/sec. (2) At one week after carotid endarterectomy: The reversed ophthalmic artery flow direction was resolved in each patient. The average peak systolic flow velocity in the patients with preoperative antegrade flow rose significantly to 0.28±0.10 m/sec (p<0.05). (3) At one month and three months after carotid endarterectomy: All patients showed the antegrade ophthalmic artery flow direction. The average peak systolic flow velocities showed no significant change compared to the value at one week after carotid endarterectomy. (4) During the followed up period, there was no patient showing worsening or recurrence of clinical symptoms including the visual symptoms.   Interpretation: Carotid endarterectomy brought about the correction of the reversed flow and an increase in the peak systolic flow velocity of the ipsilateral ophthalmic artery immediately after surgery.     

Bilateral ophthalmic origin of the middle meningeal artery

The origin of the middle meningeal artery (MMA) may vary although it can arise from the ophthalmic artery (OA) with a 0.5% prevalence. We report the exceptional bilateral asymmetric origin from the OAs that has not previously been reported in the literature. Surgeons should be aware of this variation as it could be crucial in the setting of an endovascular approach for meningeal lesions, as in our observation. A 50-year-old male underwent a preoperative cerebral digital subtracted angiography that incidentally revealed MMAs arising from the OA on both sides. In fact, the origin was asymmetric because it was complete on the right side with the anterior and posterior branches of the MMA arising from the OA, whereas it was partial on the left side, with only the anterior branch arising from the OA. The CT scan showed the absence of the foramen spinosum only on the right side. This paper discusses the unique anatomic variation in the light of MMA embryology and its different origins. Knowledge of this variation may have a practical impact in cases of cerebral embolization.     

Microsurgical anatomy around the origin of the ophthalmic artery with reference to contralateral pterional surgical approach to the carotid-ophthalmic aneurysm

The supraclinoid segments of the internal carotid artery (ICA) and their surrounding structures were examined under magnification in 25 adult cadavers. Attention was paid to anatomical variations and relationships concerning ipsilateral and contralateral pterional microsurgical approaches to these regions, especially to the origin of the ophthalmic artery. Eighty-four percent of the ophthalmic arteries arose from the supraclinoid segment of the ICA. In the ipsilateral pterional approach, mobilization of the ipsilateral optic nerve was required to see the origin of the ipsilateral ophthalmic artery and the medial aspect of the proximal portion of the supraclinoid segment of the ICA. In the contralateral pterional approach, on the other hand, these areas on the contralateral side could be identified under the optic nerve with minimal or without retraction of the contralateral optic nerve. This was because 71% of the ophthalmic arteries arose from the supero-medial aspect of the ICA, and because there was nothing to intercept the view of the medial aspect of the ICA under the optic nerve. This study supports the usefulness of the contralateral pterional approach to the origin of the ophthalmic artery and the medial aspect of the supraclinoid segment of the ICA. This approach could be useful in certain cases of carotid-ophthalmic aneurysm. The authors' experience with the contralateral pterional approach to carotid-ophthalmic aneurysms is also described.     

Ruptured aneurysm of the ophthalmic artery trunk demonstrated by three-dimensional rotational angiography: case report

OBJECTIVE AND IMPORTANCE: Aneurysms arising from the ophthalmic artery are extremely rare, compared with carotid-ophthalmic aneurysms arising from the wall of the internal carotid artery. We present a very unusual type of aneurysm arising from the ophthalmic artery itself. CLINICAL PRESENTATION: A 54-year-old man presented with a sudden onset of headache and was transferred to a local hospital. Computed tomography demonstrated subarachnoid hemorrhage around the left anterior clinoid process, but digital subtraction angiography failed to localize the source of the hemorrhage. The patient was referred to our hospital for further evaluation and treatment. Conventional cerebral angiography did not reveal the source of the hemorrhage, but three-dimensional rotational angiography clearly demonstrated an aneurysm arising from the ophthalmic artery trunk, apart from the internal carotid artery. INTERVENTION: The patient underwent microsurgical clipping of the aneurysm via a left pterional craniotomy. The aneurysm originated from the bifurcation of the ophthalmic artery and a perforating artery to the optic nerve. The aneurysm was successfully obliterated, and the postoperative course was uneventful. CONCLUSION: This report is the first to describe a case of a ruptured aneurysm arising from the ophthalmic artery trunk. We discuss the clinical significance of an aneurysm at this site, as well as the role of three-dimensional rotational angiography in determining the source of subarachnoid hemorrhage.     

Agenesis of the left internal carotid artery, common carotid artery and main trunk of the external carotid artery associated with multiple cerebral aneurysms: case report

A case of agenesis of the left internal carotid artery, common carotid artery and main trunk of external carotid artery with multiple cerebral aneurysms is presented. No similar case has been reported before. A 70-year-old man who had severe headache was admitted to the neurological department of Matsuyama Shimin Hospital. On admission he demonstrated nuchal rigidity and motor aphasia. CT scan revealed subarachnoid hemorrhage with intracerebral hematoma in the left temporal area. Right common carotid angiography, bilateral retrograde brachial angiography and aortography demonstrated an agenesis of the left internal carotid artery, common carotid artery and main trunk of external carotid artery with aneurysms of the anterior communicating artery, left middle cerebral artery and basilar tip. And these revealed that the left middle cerebral artery was fed from the basilar artery via the dilated left posterior communicating artery, and the left ophthalmic artery was originated from the left middle cerebral artery. CT of the base of the skull revealed no carotid canal on the left side. We confirmed these findings by operation. The importance of altered hemodynamic forces on the circle of Willis produced by the agenesis of the internal carotid artery and the embryological considerations are discussed.     

Hemorrhage into fibrous dysplasia following minor head injury—Effective decompression for the ophthalmic artery and optic nerve

We performed an effective optic canal decompression in a patient with ethmoid and sphenoid fibrous dysplasia and visual impairment following minor head trauma. On admission, the patient's left visual acuity consisted only of light perception, and the left ophthalmic artery was not visible by angiography. A hematoma and fibrous dysplasia tissue in the sphenoid sinus were excised and the left optic canal was decompressed. The vision was markedly improved to an ability to count fingers in the following 2 weeks. The left ophthalmic artery was fully opacified in the postoperative angiogram.     

Traumatic bilateral ophthalmic artery aneurysms: a case report

A case of bilateral ophthalmic artery aneurysm of traumatic origin is discussed. The patient presented with progressive loss of vision, memory deficit, and expressive aphasia. A computed tomographic scan revealed enhancing lesions near the region of the optic chiasm. The diagnosis of cerebral aneurysm was confirmed by cerebral angiography. At operation, bilateral ophthalmic artery aneurysms were successfully clipped.     

Some observations on aneurysms of the proximal internal carotid artery.

The author reports on 41 aneurysms of the proximal internal carotid artery (PICA) demonstrated in 36 patients with subarachnoid hemorrhage. The patients included a striking preponderance of women, and there was a high incidence of multiple aneurysms. In cases with multiple aneurysms the PICA aneurysm was usually found incidentally, a more distal aneurysm on the internal carotid artery being the source of hemorrhage. An infundibulum at the origin of a posterior communicating artery was unusually common in these patients. The origin of the ophthalmic artery is proposed as the angiographic landmark of the level at which the internal carotid artery penetrates the dura mater.     

An alternative procedure for correction of anomalous origin of left coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac malformation that is commonly associated with mitral insufficiency. Direct implantation of the anomalous origin of the left coronary artery from the pulmonary artery into the aorta is ideal, but it may not be fit for some patients whose anomalous left coronary arteries arise remotely from the ascending aorta. To solve the same technical problem in a boy with anomalous origin of the left coronary artery from the pulmonary artery in combination with moderate mitral insufficiency, we successfully elongated the anomalous coronary artery by creating a tube-shape graft using part of the pulmonary arterial wall. Simultaneous mitral annuloplasty was performed after a dual-coronary repair.     

Unusual variant of the anterior cerebral artery

A rare abnormality of the A1 segment of the anterior cerebral artery (ACA) is reported. The right ACA bifurcated into two parts at the middle point of the A1 segment, and these segments did not rejoin. The superior right A1 segment connected with the left A1 and formed a single pericallosal artery. The inferior right A1, from which the right ophthalmic artery originated, had no connection with the left A1.     

Anomalous left anterior descending coronary artery from pulmonary artery with ventricular septal defect

Anomalous origin of the left anterior descending coronary artery with associated congenital defects is very rare. An angiogram of a 47-year-old woman admitted for a ventricular septal defect closure revealed an anomalous left anterior descending coronary artery arising from the left posterior sinus of the pulmonary artery. During the surgical procedure, the origin of the left anterior descending coronary artery was closed with pledgetted polypropylene sutures through the pulmonary artery. The ventricular septal defect was closed with a patch through the right atrium, and the left anterior descending coronary artery was bypassed with the left internal mammary artery.     

Anomalous origin of the left coronary artery from the pulmonary artery A case using the autologous pulmonary arterial wall graft.

A 10-year-old girl with anomalous origin of the left coronary artery from the pulmonary artery underwent a two coronary system reconstruction with a new technique. Her left coronary artery was stenotic next to its origin and had a severe adhesion with the aorta. We made a bypass grafting between the aorta and the left coronary artery with a roll shaped transected main pulmonary arterial wall graft. The postoperative angiogram showed a good patency of a reconstructed left coronary artery. This technique is considered useful surgical option for bypass grafting to the left coronary artery when the left coronary artery has an obstructive lesion or a difficulty to dissect and mobilize.     

An intraoperative evaluation of the cerebral circulation using the ophthalmic artery Doppler method in a case of brachiocephalic trunk occlusion

A 57-year-old man underwent left-right subclavian artery bypass for brachiocephalic trunk occlusion. The cerebral circulation was evaluated by ophthalmic artery Doppler method during the operation. Before the bypass, maximal flow velocity (Vmax) of the right ophthalmic artery was 6.09 cm x sec(-1), compared to 43.8 cm x sec(-1) of the left. The preoperative flow acceleration (FA) was 8.3 cm x sec(-2) and 500 cm x sec(-2) in the right and left, respectively. Both Vmax and FA of the right ophthalmic artery improved to 17.6 cm x sec(-1) and 96.7 cm x sec(-2) at the end of the bypass. Additional sutures were performed because of difficulty in stopping bleeding at the site of anastomosis. However, this additional procedure blunted the Doppler waveform, with decreases in Vmax to 8.69 cm x sec(-1) and FA to 33.1 cm x sec(-2) Re-anastomosis at the leftsubclavian artery was performed. Anaphylactic shock induced by transfusion was encountered at the end of re-bypass. Vmax of the right ophthalmic artery at that time was only 10.2 cm x sec(-1) However, the fact, that the Doppler waveform was no more blunt and FA had improved up to 116.4 cm x sec(-2), let us conclude that the cerebral circulation had recovered. In conclusion, the ophthalmic artery Doppler method is a useful tool for evaluation of the cerebral circulation.     

High incidence of arterial dissection associated with left vertebral artery of aortic origin

The incidences of arterial dissection of the vertebral artery (VA) of aortic origin and VA of subclavian artery origin were determined. The origins of the left and right VAs were confirmed by angiography in 860 and 717 patients, respectively. Left VA of aortic origin was found in 21 patients (6 females and 15 males) but no right VA of aortic origin was found. Left VA of left subclavian artery origin was found in 837 patients and right VA of right subclavian artery origin in 717 patients. Arterial dissection of the VA occurred in 17 patients (6 females and 11 males), four patients with left VA of aortic origin, seven with left VA of left subclavian artery origin, four with right VA of right subclavian artery origin, and two with bilateral VAs of subclavian artery origin. Left VA of aortic origin (4 of 21 patients) was associated with a significantly higher incidence of VA dissection than left VA of left subclavian artery origin and right VA of right subclavian artery origin (p < 0.001). Left VA of aortic origin is associated with a predilection for VA dissection in comparison to VA of subclavian artery origin.