Long-Term Visual Outcome for Very Large and Giant Ophthalmic Segment Aneurysms: Assessment of Surgical Treatment

Objective: The treatment of very large and giant ophthalmic segment aneurysms is extremely challenging. Endovascular therapy has shown little success in improvement of optic pathway compressive symptoms. We hypothesize whether surgical treatment of these aneurysms yields a better result in terms of visual function and aneurysm obliteration. Methods: The Toronto Brain Vascular Malformation Study Group database was analyzed to retrieve patients treated surgically for very large (>15 mm) and giant aneurysms of the ophthalmic segment of the carotid artery. Preoperative and postoperative long-term outcome with specific consideration for visual function (based on formal neuro-ophthalmological examination) and degree of aneurysm obliteration were evaluated. Results: Of the 257 patients with ophthalmic and paraophthalmic aneurysms, 37 had very large or giant aneurysms. Twenty patients underwent surgical treatment; 18 of these had direct clipping, 1 had trapping of the aneurysm, and 1 underwent trapping and bypass. Fourteen patients had unruptured and six had ruptured aneurysms. The mean follow-up period was 88 months. Six aneurysms had small residual neck remnant (30%). Of the 11 patients with documented preoperative visual deficit, 8 improved (73%), 2 (27%) remained stable, and 1 (5%) worsened. Three patients had mild to moderate new visual deficit, which brings the surgery-related visual complications to 15%. Seventeen patients (85%) had a good or excellent outcome (GOS IV and V). Conclusion: There is considerable surgery-related risk for optic pathways during treatment of very large and giant ophthalmic segment aneurysms. Surgery, however, seems to be the treatment of choice in terms of overall visual function outcome and aneurysm obliteration compared with the current endovascular results in this subset of patients.