Evaluation of the anastomoses between the ophthalmic artery and the middle meningeal artery by superselective angiography.

PURPOSE: There are three anastomoses between the ophthalmic artery (OA) and the middle meningeal artery (MMA): the anastomotic branch with MMA, the recurrent meningeal branch and the anterior falx artery. We aimed to evaluate the anastomotic branches between the OA and the MMA on superselective angiograms of pediatric patients with retinoblastoma. MATERIALS AND METHODS: We evaluated 126 angiographies performed on children with retinoblastoma. The mean diameter and angiographic visibility percentage of the anastomotic branches between the OA and the MMA were examined according to age group and sex. RESULTS: The mean diameter of anastomotic branch with MMA was measured 0.58 ± 0.13 mm and we found this branch in 15 of 126 angiographic images (11.9%). We detected the recurrent meningeal branch in 47 of total images (37.3%). The recurrent meningeal branch arose 85.1% from the lacrimal artery, 8.5% from the anastomotic branch with MMA and 6.4% directly from the OA. The mean diameter of this artery was measured 0.21 ± 0.06 mm. Anterior falx artery was found in 86 of 126 angiographic peocedures (68.3%) and the mean diameter was measured 0.22 ± 0.06 mm. CONCLUSION: Knowledge of the anastomoses between the OA and the MMA system are all necessary to perform safe and successful endovascular and surgical procedures involving the orbital region.

Analysis of anatomical variation of the inclination of lamellas attached to the skull base and its correlation with the anterior ethmoidal artery floating in the ethmoid sinus for use in endoscopic sinus surgery.

PURPOSE: Attention to the inclination of lamellas attached to the skull base, including the basal lamella of the middle turbinate, facilitates the intraoperative identification of each lamella without requiring the use of a navigation system. We classified the inclination between the lamella and the skull base in preoperative computed tomography (CT) images and examined the relationship between the lamellas attached to the skull base, including the basal lamella of the middle turbinate, and the position of the anterior ethmoidal artery (AEA). We aimed to develop a preoperative classification to help prevent intraoperative injury of the AEA. METHODS: We retrospectively investigated the paranasal sinus sagittal section CT slices of 366 sides of 183 patients to assess the inclination of lamellas attached to the skull base and the AEA location. We also reviewed the AEA position, its correlation with the supraorbital ethmoid cell, and the lateral lamella of the cribriform plate. RESULTS: We classified the lamella inclination at the skull base as the anterior direction, perpendicular direction, and posterior direction types. Lamellas containing a floating AEA inclined in the anterior direction toward the skull base were observed in 68.9% of sides, inclination in the perpendicular direction was noted in 30.5% of sides, and inclination in the posterior direction was noted in 0.5% of sides. CONCLUSION: It is easier to identify the AEA intraoperatively when the lamella inclination of the skull base attachment is recognized based on preoperative CT findings. This approach could be applied to all paranasal sinus lamellas and assist in identifying the AEA and other nearby structures.

Traumatic subarachnoid hemorrhage related to ophthalmic artery avulsion: a case report.

We present a case of ophthalmic artery (OA) traumatic avulsion, leading to a post-traumatic subarachnoid hemorrhage (SAH) with ventricular blood invasion and hydrocephalus, mimicking an internal carotid aneurysm rupture. This is the third case of such an event reported in literature and the first without orbital fractures and optic nerve avulsion. Conservative treatment was sufficient for the avulsion, but surgery was needed for the coexisting eye luxation. Traumatic OA avulsion is a rare but possible event and should be suspected in case of basal cisterns SAH, evidence of orbital trauma and CT angiogram or angiographic absence of opacification of the OA.

Diffuse Traumatic Subarachnoid Hemorrhage Mimicking Aneurysmal Bleeding Secondary to Ophthalmic Artery Avulsion: Case Report and Review of the Literature.

BACKGROUND: Traumatic subarachnoid hemorrhage (SAH) is a common finding following traumatic brain injury. In some cases, it can be associated with hydrocephalus. This type of hemorrhage is mostly caused by the rupture of small vessels in the brain and is usually managed conservatively. CASE DESCRIPTION: We present a case of a 60-year-old woman who presented with traumatic luxation of the eye following a fall. This resulted in diffuse SAH (Fisher grade IV) with associated hydrocephalus. We also report on 3 previous similar cases found in the literature. Avulsion of the ophthalmic artery was found to be the cause of the traumatic SAH. Apart from cerebrospinal fluid diversion using an external ventricular drain, the case was managed conservatively. There was no evidence of delayed clinical or radiologic vasospasm. CONCLUSIONS: Traumatic avulsion of the ophthalmic artery may result in diffuse SAH, mimicking that of aneurysmal rupture. This case shows that management of early complications, such as hydrocephalus and seizures, should be the main aim. Surgical or endovascular treatment of the injured artery, however, would be unnecessary.

Anatomical and ultrasound-based injections for sunken upper eyelid correction.

BACKGROUND: A needle or a cannula can be safely used during filler injection procedures to correct a sunken upper eyelid. To date, there are no precise injection points recommended that are based on an anatomical study. OBJECTIVE: This study systematically investigated the vascular pattern and depth of forehead arteries at the periorbital area of upper eyelid. METHODS: Twenty cadavers were dissected in this study. Additional data were obtained from 30 healthy volunteers using Doppler ultrasound imaging with high-frequency probe. RESULTS: The ophthalmic artery divided into two opposite primary branches: the superior and inferior orbitoglabellar arteries running along the orbital rim. After the supratrochlear artery arose from the superior orbitoglabellar artery at the medial eyebrow, the supraorbital artery either divided from this artery near the supraorbital foramen or emerged as an individual artery from the supraorbital notch. The inferior orbitoglabellar artery gave off the radix artery superior to the medial canthal tendon. The radix artery divided into two opposite branches: the dorsal nasal artery going to the nose and the paracentral artery going to the glabella. Ultrasound imaging revealed a subcorrugator space that a cannula can safely pass through. At the supraorbital foramen/notch, the supraorbital artery traveled very close to the bone. Based on the anatomical data collected, the following injection points for a needle and a cannula technique are recommended. CONCLUSION: Correction of a sunken upper eyelid is a dangerous procedure which should be performed only by experienced physicians. However, with precise anatomical knowledge and correct techniques, optimal outcomes can be safely achieved.

Association of Autologous Fat Injection in Facial Artery With Ophthalmological Complications: An Experimental Animal Study.

IMPORTANCE: Complications caused by autologous fat filling have been reported. Comprehensive knowledge of the possible adverse effects of autologous fat filling is needed. OBJECTIVE: To determine the association of autologous fat filling with ophthalmic function complications. DESIGN, SETTING, AND PARTICIPANTS: Four adult New Zealand white rabbits were killed for a facial anatomy study. Sixty-four adult New Zealand white rabbits underwent fat harvest using the Coleman technique. Autologous fat was minced or digested with collagenase 1 and centrifuged to separate fat lipid and fat granules. Either 0.2 mL or 0.4 mL of minced fat, fat granules, fat lipid, or saline (control) was retrogradely injected into the facial artery of rabbit models. Electroretinography and ophthalmic fundoscopy were performed to measure the retina and fundus artery occlusions 2 weeks after surgery. MAIN OUTCOMES AND MEASURES: Visual impairment, blindness, and death. RESULTS: Injection of 0.2 mL of fat granules, fat lipid, and saline resulted in 100% (8 of 8), 62.5% (5 of 8), and 0 ophthalmic complications, respectively; and 0.4 mL resulted in 87.5% (7 of 8), 12.5% (1 of 8), and 0 ophthalmic complications, respectively. Injection of 0.2 mL and 0.4 mL minced fat led to 100% (8 of 8) ophthalmic complications and death, respectively. The mortality rates were 37.5% (3 of 8), 12.5% (1 of 8), and 0 for 0.2 mL emboli injection, and 100% (8 of 8), 50% (4 of 8), and 0 for 0.4 mL, respectively. CONCLUSIONS AND RELEVANCE: In this study, minced fat injection was associated with more ophthalmic complications than injection of fat granules and fat lipid. Increasing the injection volume of fat tissues could raise the incidence of morbidity and mortality. LEVEL OF EVIDENCE: NA.

Diffusion-Weighted Imaging Changes in a Child With Posterior Ischemic Optic Neuropathy.

BACKGROUND: Posterior ischemic optic neuropathy results from ischemia of the retrobulbar aspect of the optic nerve. It presents as acute loss of vision without optic disc swelling. This is rare in children, with only seven cases reported to date. Neuroimaging is frequently used to aid in the diagnosis of acute visual complaints in children; however, none of the cases described to date delineate the neuroimaging findings of this entity in children. METHODS: We retrospectively reviewed the electronic medical record. RESULTS: We describe the MRI findings in a 10-month-old boy with posterior ischemic optic neuropathy after intraophthalmic artery injection of chemotherapy for retinoblastoma. CONCLUSIONS: As targeted therapies for retinoblastoma and other diseases amenable to intravascular treatment delivery are more frequently used, the risk of grave vision-related side effects increases. Posterior ischemic optic neuropathy should be considered in the differential diagnosis of any child presenting with acute loss of vision. Dedicated imaging of the orbits can elucidate specific findings that may aid in the diagnosis of this entity in children.

Haematoma of anterior ethmoidal artery after reduction of fracture of zygomatic complex.

Extraconal intraorbital haemorrhage is a rare complication after reduction of a fracture of the zygomatic complex. We present a case of postoperative intraorbital haematoma that arose from the anterior ethmoidal artery. We stress the advantages of imaging before decompression and of the medial approach.

Massive Hemorrhage from the Posterior Ethmoidal Artery during Transsphenoidal Surgery: Report of 2 Cases.

Nasal bleeding is a major complication that can occur during and after transsphenoidal surgery (TSS) for intra- and suprasellar tumors. In most cases, the cause of this bleeding can be attributed to a branch of the maxillary artery called the sphenopalatine artery, injury to which can lead to life-threatening situations. Upon exposure of the suprasellar region and planum sphenoidale during surgery, it is also important to avoid damaging the posterior ethmoidal artery (PEA), a branch of the ophthalmic artery. While recent advancement in endoscopic techniques enables the performance of extended TSS, the chances of PEA injury seem to be increasing. In the current report, we present two cases that showed massive PEA bleeding during regular (not extended) TSS. The total blood loss was 2280 ml and 2150 ml, and endoscopic views disturbed by the massive hemorrhages remarkably delayed accurate stanching of the responsive artery. Therefore, anatomical recognition of the PEA is required to avoid fatal hemorrhaging during even regular TSS, especially for the beginners of this surgery.

Sudden occlusion of the retinal and posterior choroidal circulations in a youth.

A 14-year-old boy was stabbed above the left eye and had subsequent loss of both retinal and choroidal perfusion to the posterior segment. Ophthalmoscopic examination ten days after the injury disclosed intense nerve fiber layer edema, most prominent in the posterior pole, and absence of a cherry-red spot. Intravenous fluorescein angiography showed no filling of retinal vessels and only patchy, segmental, peripapillary choroidal filling, probably secondary to collateral circulation developing from the episcleral arterial plexus. Leakage of dye from the peripapillary choroid into the overlying retina was caused by ischemic necrosis of the retinal pigment epithelium. Follow-up examination 11 days later revealed marked sclerosis of the smaller arterioles, optic pallor, atrophic retinal pigment epithelial changes, and loss of retinal substance, most marked in the posterior pole.

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.

Rupture of a large ophthalmic segment saccular aneurysm associated with closed head injury: case report.

OBJECTIVE AND IMPORTANCE: Although each year approximately 30,000 to 50,000 cases of subarachnoid hemorrhage in the United States are caused by the rupture of intracranial saccular aneurysms, there is little information in the literature documenting the association of aneurysmal rupture with closed head injury. CLINICAL PRESENTATION: A 61-year-old woman presented after a motor vehicle accident with multiple injuries, including a severe closed head injury. Computed tomography revealed a diffuse basal subarachnoid hemorrhage. Angiography revealed the source as a large aneurysm arising from the ophthalmic segment of the left carotid artery. INTERVENTION: After the patient was stabilized for her multiple injuries, she underwent craniotomy and clipping of the aneurysm. She recovered without developing new neurological deficits. CONCLUSION: Although the association of head trauma and aneurysmal subarachnoid hemorrhage is rare, the presence of significant basal subarachnoid blood on a computed tomographic scan should alert the physician to the possibility of a ruptured aneurysm.

Pulsating unilateral exophthalmos due to traumatic aneurysm of the intraorbital ophthalmic artery. Case report.

A case of pulsating unilateral exophthalmos is presented. It was caused by a traumatic aneurysm of the intraorbital ophthalmic artery, secondary to missile injury. Evolution of the aneurysm was observed clinically, by angiography, and by computerized tomography. The differential diagnosis of pulsating exophthalmos and the pathogenesis of such aneurysms are briefly discussed.

Delayed post-traumatic pseudoaneurysmal formation of the intracranial ophthalmic artery after closed head injury. Case report.

A 42-year-old male presented with a rare case of delayed aneurysmal formation of the intracranial ophthalmic artery after closed head injury manifesting as subarachnoid hemorrhage. Initial magnetic resonance angiography revealed no aneurysmal formation, but angiography 7 days after the injury demonstrated an intracranial ophthalmic artery aneurysm. Follow-up computed tomography angiography demonstrated enlargement of the aneurysm. The aneurysm was successfully treated by surgical resection. Histological examination revealed that the aneurysm was a pseudoaneurysm. Traumatic intracranial aneurysm (TICA) is rare and usually occurs in the peripheral arteries of the cerebral circulation or the basal portion of the internal carotid artery. The present case shows that failure to demonstrate an aneurysm on the initial angiography in the acute stage does not exclude the presence of traumatic aneurysm. This case clearly shows the time course of development of a TICA of the ophthalmic artery after closed head injury.

Foreign body embolus to ophthalmic artery following penetrating trauma of the neck.

Migration of metallic foreign body into the cerebral circulation is rarely seen. Most of the cases reported were due to gunshot wounds and shotgun wounds to the neck and face. When the foreign body is near the great vessel, it must be removed immediately or will cause complications. This study reported a case of delayed metallic foreign body embolus to the ophthalmic artery resulting from an injury to the right neck, which arose from the presence of metallic emboli to the cerebral circulation.

Traumatic enucleation with avulsion of the ophthalmic artery resulting in aneurysm-like subarachnoid hemorrhage.

Traumatic, nonaneurysmal subarachnoid hemorrhage (SAH) is common after closed head injury and most often results from ruptured cortical microvessels. Here, the authors present the case of a 60-year-old woman who fell and struck her head, causing traumatic enucleation and avulsion of both the optic nerve and ophthalmic artery. The arterial avulsion caused a Fisher Grade 3 SAH. During her stay in the intensive care unit, hydrocephalus and vasospasm developed, clinical conditions commonly observed after aneurysmal SAH. Epileptiform activity also developed, although this may have been related to concurrent Pantoea agglomerans ventriculitis. It is reasonable to suggest that intracerebral arterial avulsion with profuse arterial bleeding may be more likely than traditional traumatic SAH to result in clinical events similar to that of aneurysmal SAH. Special consideration should be given to the acute care of patients with intracranial arterial avulsions (conservative management vs surgical exploration or endovascular treatment), as well as long-term follow-up for vascular or other neurosurgical complications.