A C T A O P H T H A L M O L O G I C A V O L . 4 7 1 9 6 9

From the Department of Neurosurgery G (Head: Richard Malmros), and the Department of Ophthalmology (Head: Viggo A. lensen),

Arhus Municipal Hospital, Denmark

OCULAR SYMPTOMS IN SACCULAR ANEURYSMS OF THE INTERNAL CAROTID ARTERY

(A Survey of 100 Cases)

BY

RUTH RllSE

Introduction

During the past two decades, more and more exact definitions of the clinical manifestations of intracranial aneurysms have been given.

Ophthalmologists must be aware of the neuro-ophthalmologic symptoms of intracranial aneurysms which, according to Dandy (1944) are localized mostly in the internal carotid artery and involving the oculomotor, the trochlear, the abducens, the optic and the trigeminal nerves.

In a review of the clinical findings in ophthalmoplegia, Godtfredsen (196.3) showed that 30-35 O/o of patients with ophthalmoplegia had an intracranial aneurysm.

According to their localization in relation to the anterior clinoid process, the internal carotid aneurysms are classified under supraclinoid and infraclinoid aneurysms. The supraclinoid group comprises mainly aneurysms located at the origin of the posterior communicating artery whilst the infraclinoid aneurysms are located within the cavernous sinus. This is an appropriate grouping, since both symptomatology and treatment differ in the two groups.

A study of 102 intracranial aneurysms, published by Henderson in 1955,

Received January Slst 1969.

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Fig. I . Supraclinoid internal carotid aneurysm.

Fig. I I . Infraclinoid internal carotid aneurysm.

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showed that 35 of the 40 internal carotid aneurysms found were supraclinoid and 5 were infraclinoid.

In most cases the primary symptoms in supraclinoid aneurysms will be split- ting headache and stiffness of the neck caused by a subarachnoid bleeding. Pa- pilloedema and haemorrhage of the fundus are then frequent findings ( P . Ras- nzussen (1965). Associated with these symptoms there will often be partial or total oculomotor palsy. Less frequently trochlear and abducens palsy will occur. In cases without subarachnoid haemorrhage, the most frequent finding will be oculomotor palsy, often appearing as a slight ptosis, subsequently developing into palsy of the ocular muscles and pupillary changes (Henderson (1955)).

Subarachnoid bleeding is a rare occurrence in infraclinoid carotid aneurysms. As these aneurysms are usually large, they are frequently associated with ex- ophthalmos. Oculomotor palsy is a frequent finding and, in most cases, it is associated with trochlear and abducens palsy (Henderson 1955)). The corneal sensitivity will often be reduced in consequence of the lesion of the trigeminal nerve. (Je f ferson (1938, Bonnet (1955), Meadows (1959), Jaeger (1950)).

Blurring of vision or visual field defects - most often homonymous - caused by the optic nerve lesion, compression of the optic chiasm or lesion of the optic tract will occur in both supraclinoid and infraclinoid aneurysms. (Wilbrand & Saenger (1900), Jef ferson (1937 and 1955), Walsh (1964)).

Furthermore, in either group of patients, the presenting signs of the aneurysm will frequently be of an ocular nature. Hence, Zielinski (1957) found that 480/0 of patients with saccular aneurysms of the internal carotid artery complained primarily of ocular symptoms.

Most of the patients have headache, frequently as facial pain and in some cases located in the eye. (P. Rasmussen (1965)).

Because of more exact roentgenologic diagnosis and improved surgical methods, the prognosis in aneurysms have become much more favourable during recent years. Early operation provides the best results (Bolterell et al. (1962), Henry Troupp et al. (1958)). Following surgery the ophthalmoplegia will often improve, although on rare occasions only, it disappears completely. A slight ptosis and, in some cases, slight dilatation of the pupil will remain, but usually these symptoms do not give rise to any complaints (HePpler & Cantu (1967)).

Own material

As regards all patients admitted to the Department of Neurosurgery G, Arhus Municipal Hospital, over the period from April Ist, 1943, to March 31st, 1965, with a diagnosis of saccular aneurysm of the internal ‘carotid artery, the records were reviewed with respect to the ocular symptoms.

During the above period, 201 patients were admitted with saccular intra- cranial aneurysms. In 108 cases the aneurysm was located on the internal caro-

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tid artery. Eight patients were excluded because it was impossible to undertake an ophthalmologic examination.

Primarily, the location of the aneurysm was determined by arteriography. Only patients with a positive arteriographic diagnosis were operated on. Gene- rally, the findings at arteriography, surgery and, in some cases, at autopsy showed good concurrence.

General data

Sex

Males 38

Females 62

The preponderance of females as regards internal carotid aneurysms agrees with the figures given by Henderson. When intracranial aneurysms are viewed collectively, the sex incidence is almost equal.

< 40 years 40-60 years > 60 years 34 53 13

The average age is low, but the spreading is appreciable (12-74 years).

Location

Supraclinoid Infraclinoid 92 8

Right side Left side 51 49

It will be seen that by far the greater number of internal carotid aneurysms were supraclinoid, which corresponds to the findings of previous authors (Dandy (1944), Henderson (1955)).

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Number of aneurysms

One Multiple 91 9

In addition to the internal carotid aneurysms, one or more aneurysms were found on one of the intracranial vessels in 9 cases. However, in all these cases the symptoms could be ascribed most likely to the aneurysm found on the inter- nal carotid artery.

In the majority of patients the blood pressure recorded on admission was normal. Subarachnoid haemorrhage occurred both in patients with high blood pressure and with normal blood pressure.

Blood pressure

With Without Diastolic blood pressure subarachnoid subarachnoid Total 1 haemorrhage 1 haemorrhage 1

> 100 < 100 Not stated

11 64

2

2 21 0

13 85 2

Total 7 7 23 100

Complaints

The most frequent complaint in patients with saccular internal carotid aneu- rysms was headache. This symptom was reported by 95 patients. In most cases there was a dull frontal headache. In 1 1 patients the pains were located in the eye on the side of the aneurysm. Headache, not associated with rupture of the aneurysm or eye symptoms, was reported in 9 cases. Headache assiciated with eye symptoms and without clinical signs of rupture of 'the aneurysm occurred in 16 cases. In these cases the symptoms might indicate growth of the aneurysm. In 70 cases the headache developed in connection with rupture of the aneurysm. and in these cases the pain occurred suddenly and was violent.

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Forty-eight patients were suffering from ocular complaints on admission, and in 19 patients the symptoms were not related to a rupture of the aneurysm. In 1 1 of the patients, the symptoms had persisted for more than 12 months, in two of them the period was between 6 and 12 months, whilst the remaining 35 patients had had the symptoms for less than 6 months. In more than 50 O/O of the cases the symptom was diplopia. Some of the patients complained of ptosis. Blurring of vision was a rare complaint, as compared with the findings at the objective examination.

In 52 patients without primary ocular symptoms, the presenting finding war most often subarachnoid bleeding, this symptom being present in 46 of these patients. Of the remaining 6 patients the cause of admission, in 5 cases, was headache and mental disturbances in one.

Objective findings

The objective findings a t ocular examination on admission showed a domina- tion of oculomotor palsy. This symptom was found in 39 cases, and in 29 of these total palsy (involving all branches), was observed. In the majority of cases the palsy had commenced as a slight ptosis and had then developed over days, weeks or months into total palsy. Most frequently a rapid development of this symptom was associated with subarachnoid haemorrhage, (in 26 of the 39 patients suffering from oculomotor palsy, subarachnoid bleeding was pre- sent). Of the 10 cases with partial oculomotor palsy, ptosis was recorded in 9 cases, palsy of the superior rectus muscle in 7 cases, palsy of the sphincter of the pupil in 6 cases, and palsy of the medial rectus muscle in 4 cases.

Trochlear and abducens palsy and lesion of the trigeminal nerve (reduced corneal sensivity) occurred mainly in infraclinoid aneurysms.

Exophthalmos was found in one case only, in connection with infraclinoid aneurysm. The protrusion was only moderate.

Visual field defects were recorded in four cases associated with supraclinoid aneurysms. The defects appeared mainly as homonymous hemianopsia.

Papilloedema was observed in 18 cases - in connection with subarachnoid bleeding exclusively. The associated haemorrhages were mainly streaky and of a peripapillary location. In a few cases there was pre-retinal bleeding.

In 39 cases (38 supraclinoid and 1 infraclinoid), the visual acuity was not tested because of poor general condition. The group “blurring of vision” com- prises patients with < 619 on the defective eye.

Most likely the occurrence b f pqlsy of the ocular muscles, visual field defect and reduced corneal sensitivity is much higher than that demonstrated in our material, since many of the patients with subarachnoid bleeding were too weak to undergo a thorough examination.

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100 cases of saccular aneurysms of the internal carotid artery

ocular symptoms 92

supraclinoid 8

infraclinoid 100 total

Oculomotor palsy Trochlear palsy Abducens palsy Reduced corneal sensitivity Exophthalmos Visual field defect Papilloedema Optic atrophia Haemorrhage Blurring of vision

34 0 1

4 0 4

18 5

19 1 G

5 1 4

(The figure in the brackets indicate the number of subarachnoid bleedings).

Sixty-eight patients underwent surgery. I n cases of supraclinoid aneurysms, ligation of the aneurysm, combined, if necessary, with muscle wrapping, was conducted. As regards infraclinoid aneurysms, ligation of the carotid artery was carried out in the neck on the same side as the aneurysm.

Thirty-two patients died in hospital, and a further 8 patients died within one year after discharge. In 13 of the 40 patients who died, ocular symptoms were the presenting sign, whereas in 27 patients other presenting symptoms were observed (mainly subarachnoid haemorrhage). Hence, the prognosis seems to be most favourable if the primary symptoms of the aneurysm are of an ocular nature and, in particular, if the patient is admitted to hospital before the oc- currence of subarachnoid bleeding.

Thirty-five of the 48 patients who complained of ocular symptoms, were still alive after one year. A written inquiry to these patients, concerning inter alia the presence of ocular symptoms, produced the following results:

Subjective ocular symptoms after one year

Improved Unchanged Worse Total

Wi th surgery 23 5 0 28 Without surgery 3 3 1 7

Total 26 (18) 8 (4) 1 (0) 35 (22)

(The figures in brackets indicate the number of subarachnoid haemorrhages.)

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Conclusion

The internal carotid artery is the most frequent location for saccular intra- cranial aneurysms (approximately 50 O / O ) . Aneurysms a t this location will most often be associated with ocular symptoms. The ocular symptoms are determined by the anatomical conditions, because the internal carotid artery throughout its course is closely related to the oculomotor, the trochlear, the adducens, the trigeminal and the optic nerves. The incidence of saccular carotid internal aneurysms is highest among females in the age group from 40-60 years. The most frequent location is supraclinoid (92 O / O ) .

The majority of patients complain of headache. The presenting ocular symp- toms are ptosis and diplopia, as a result of oculomotor palsy which is present in 39 O/O of the cases. Abducens palsy and lesion of the trigeminal nerve occur mostly in connection with infraclinoid aneurysms. Trochlear palsy, exophthal- mos, visual field defect, blurring of vision, and papillary atrophy are rare symptoms.

Headache and ocular symptoms occur most frequently in connection with subarachnoid bleeding. However, 19 O / O of the patients presented ocular symp- toms without subarachnoid bleeding. I n cases without rupture of the aneurysm, headache and ocular symptoms might indicate growth of the aneurysm.

After surgery most of the patients report improvement of the ocular symp- toms. The prognosis is best in cases where the aneurysm is diagnosed and treated before rupture occurs.

Summary

We have reviewed the records of 100 patients in whom saccular aneurysm of the internal carotid artery had been diagnosed, and who were admitted to the Department of Neurosurgery over a period of 22 years, with a view to ocular symptoms. These symptoms are related partly to the location of the aneurysm and partly to the occurrence of subarachnoid bleeding.

References

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Author’s address: Klintedalen 2, 3520 Farum, Denmark.

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