Aneurysms of the ophthalmic segment. A clinical and anatomical analysis

The clinical, radiographic, and anatomical features in 80 patients with ophthalmic segment aneurysms were reviewed, and were categorized according to a presumed origin related to the ophthalmic (41 cases) or superior hypophyseal (39 cases) arteries. There was a marked female predominance (7:1) and high incidence of multiple aneurysms (45%) within this population. Clinical presentations included subarachnoid hemorrhage in 23 cases (29%) and visual deficits in 24 (30%); five patients exhibited both hemorrhage and visual loss. Twenty-eight aneurysms were incidentally identified. Ophthalmic artery aneurysms arose from the internal carotid artery (ICA) just distal to the ophthalmic artery, pointed superiorly or superomedially, and (when large) deflected the carotid artery posteriorly and inferiorly, closing the siphon. Abnormalities relating to vision were not identified until the aneurysm realized giant proportions. The optic nerve was typically displaced superomedially, which restricted contralateral extension until late in the clinical course; unilateral nasal field loss was seen in 12 patients. Nine patients had bilateral ophthalmic artery aneurysms which were often clipped via a unilateral craniotomy. Superior hypophyseal artery aneurysms arose just above the dural ring from the medial bend of the ICA, at the site of perforator origin to the superior aspect of the hypophysis, and had no direct association with the ophthalmic artery. The carotid artery was usually located lateral or superolateral relative to the aneurysm. These lesions could extend medially beneath the chiasm (suprasellar variant), producing a clinical and computerized tomography picture similar to a pituitary adenoma, or they could extend ventrally to burrow beneath the anterior clinoid process (paraclinoid variant). Preoperative categorization of these lesions according to their likely branch of origin provides excellent correlation with visual deficits and operative findings, and has allowed the author to clip 52 of 54 lesions, with very low operative or visual morbidity.