An ophthalmic artery occlusion after a craniotomy using the pterional approach: A report of three cases, one resulting in blindness

Abstract

The authors present three cases of an ophthalmic artery occlusion after a pterional craniotomy, one case resulting in sudden blindness and two cases in which vision was preserved. The male patient who developed blindness was admitted because of a subarachnoid hemorrhage. Selective internal carotid angiography revealed aneurysms at the right A3 bifurcation and at the M1 bifurcation, but the ophthalmic artery was not found. The patient underwent a two-stage operation. For the first stage, using an interhemispheric approach, the A3 aneurysm was successfully clipped with no neurological deficit. For the second stage, a pterional approach was used and the M1 aneurysm was clipped. Postoperatively, however, the right eye lost all vision and manifested a cherry-red-spot fundus, and it is suspected that the blindness may have been caused by postoperative occlusion of the ophthalmic artery arising from the middle meningeal artery. In the other two cases, selective internal carotid angiography revealed aneurysms, and based on selective external carotid angiography, the ophthalmic artery appeared to originate from the branch of the middle meningeal artery. These two patients underwent pterional craniotomy with careful removal of sphenoid ridge, so as to avoid injurying the orbital ramus of the middle meningeal artery, and the aneurysms were successfully clipped. When a pterional craniotomy is performed for patients in whom the ophthalmic artery is being primarily supplied from the branch of the external carotid artery, the authors urge that careful attention be paid to all aspects of the surgery.