Stapedial Artery: From Embryology to Different Possible Adult Configurations.

The stapedial artery is an embryonic artery that represents the precursor of some orbital, dural, and maxillary branches. Although its embryologic development and transformations are very complex, it is mandatory to understand the numerous anatomic variations of the middle meningeal artery. Thus, in the first part of this review, we describe in detail the hyostapedial system development with its variants, referring also to some critical points of ICA, ophthalmic artery, trigeminal artery, and inferolateral trunk embryology. This basis will allow the understanding of the anatomic variants of the middle meningeal artery, which we address in the second part of the review.

Combined Surgical and Endovascular Treatment of an Intraorbital Arteriovenous Fistula Drained Into a Basal Vein of Rosenthal: A Technical Case Report.

BACKGROUND: Intraorbital arteriovenous fistulas (AVFs) are rare lesions, and their treatment is challenging. We have presented a case of an intraorbital AVF treated with endovascular embolization through the surgically accessed basal vein of Rosenthal. CASE DESCRIPTION: A 53-year-old man had been referred to our hospital for an aneurysm-like lesion that was compressing the left optic chiasm. A left internal carotid angiogram demonstrated an orbital AVF fed by a distal segment of the ophthalmic arteries and the anterior branch of the inferolateral trunk that was drained solely into a tortuous basal vein of Rosenthal through a bridging vein of the left optic nerve sheath. Considering the risk of hemorrhagic complications during transvenous manipulation and visual complication in cases of transarterial embolization, combined surgical and transvenous embolization was attempted through the translocated basal vein of Rosenthal to bypass the dangerous path to the fistula. The lesion was directly catheterized through the translocated basal vein of Rosenthal after confirming visual tolerance to brief drainage occlusion using visual evoked potential monitoring, resulting in successful fistula obliteration using detachable coils. CONCLUSION: Direct catheterization of the translocated deep draining vein was useful to bypass the dangerous access to the fistula and could be a feasible alternative strategy for treating selected AVFs.

Bilateral anomalous origin of ophthalmic artery from middle meningeal artery and coincidence of bilateral carotid artery aneurysm: Case report and literature review.

Ophthalmic artery (OA) is known for anomalous origin and aberrant course probably attributable to its complex embryology. Anomalous origin of OA can be associated with intracranial aneurysm. Anomalous origins have been reported from middle meningeal artery (MMA), cavernous carotid, posterior communicating, anterior cerebral and basilar artery. Even though bilateral anomalous origin of OA from MMA is a rare finding, to the author's best knowledge, association of above condition with bilateral internal carotid artery aneurysms has not been described in the literature. We present a case of such anomalous bilateral OA originating from MMA and associated with bilateral internal carotid artery aneurysms. We have also reviewed the pertinent literature regarding anomalous OA origin.

Anomalous origin of the middle meningeal artery from the inferolateral trunk with an arterial circle around a hypoplastic internal carotid artery in an infant with a dural arteriovenous fistula.

Deviations from normal embryologic development can manifest in different anatomical variants of the ophthalmic artery. We present a case of an infant treated for a high-flow dural arteriovenous fistula of the superior sagittal sinus, in whom an arterial circle involving the ophthalmic artery, the middle meningeal artery, the inferolateral trunk and a hypoplastic segment of the internal carotid artery was found. The embryologic development is briefly reviewed with emphasis on the possible genesis of this interesting constellation.

Carotid-anterior cerebral artery (ACA) anastomosis associated with azygos ACA and ophthalmic artery arising from the middle meningeal artery: a case report.

Among variations of the anterior cerebral artery (ACA), anastomosis of its A1-A2 junction with the ophthalmic segment of the internal carotid artery is rare and described as carotid-ACA anastomosis or infraoptic course of the ACA. One common variant, an azygos ACA, demonstrates no pairing of the A2 segment. To our knowledge, association of a carotid-ACA anastomosis with an azygos ACA is not reported in the English-language literature. We report a case diagnosed by magnetic resonance angiography in which right carotid-ACA anastomosis was associated with an azygos ACA and the right ophthalmic artery originated from the middle meningeal artery.

The ophthalmic artery: a new variant involving two branches from the supracavernous internal carotid artery.

PURPOSE: We report an extremely rare, double ophthalmic artery configuration. METHODS: We present 2D- and 3D-angiographic features of an anomalous origin of the ophthalmic artery. RESULTS: The double ophthalmic artery was the result of the persistence of the primitive dorsal ophthalmic artery combined with the presence of a second orbital artery originating from the supracavernous internal carotid artery, passing through the superior orbital fissure and into the orbit to furnish the muscular, lacrimal and ethmoidal arteries and the medial long posterior ciliary artery. CONCLUSIONS: A heretofore undocumented instance of ophthalmic artery duplication is presented. Knowledge of such variations is important for the planning of endovascular treatments and the comprehension of unusual angiographic images. Such fine arterial variants may very well be frequent, but difficult to demonstrate on simple 2D angiographies. Multiplanar reconstructions of 3D angiography data make it possible to diagnose rare, but embryologically predictable arterial variants.

Anomalous Origins of Ophthalmic Arteries on Three-Dimensional Time-of-Flight Magnetic Resonance Angiography and Their Clinical Importance.

AIM: The purpose of this paper was to evaluate rare cases of anomalous origins of the ophthalmic artery (OA) according to magnetic resonance angiography (MRA) findings. METHODS: This retrospective study included 80 patients diagnosed with anomalous OA origins between March 2015 and July 2018 from a sample of 16,024 patients. The patients included 47 females and 33 males with a mean age of 38.16 years (range 18-62 years). Three-dimensional time-of-flight (3D-TOF) MRA was performed for all patients. RESULTS: Eighty (0.5%) patients had anomalous OA origins. The most common type of OA origin anomaly was the right OA originating from the middle meningeal artery (0.17%). Twelve (0.07%) patients had OAs with an extradural origin. CONCLUSIONS: Anomalous origins of the OA are rare. 3D-TOF MRA is a noninvasive imaging method that can be applied for the diagnosis of OA anomalies. Some OA variations can have a protective effect against ocular complications in vaso-occlusive events. Therefore, it is critical to know the variant anatomy of OAs.

Ophthalmic Arteries Arising from the Bilateral Anterior Cerebral Arteries Diagnosed by Three-Dimensional Time-of-Flight Magnetic Resonance Angiography.

BACKGROUND: The ophthalmic artery (OA) is a very important branch of the supraclinoid segment of the internal carotid artery. Origination of the OA from the anterior cerebral artery is an extremely rare condition. Being unaware of the origin anomalies of OAs can lead to unfavorable results, especially in cases in which craniofacial surgery or cerebral therapeutic angiography is planned. CASE DESCRIPTION: An anomalous origin of the ipsilateral OAs from the A1 segments of the bilateral anterior cerebral arteries was detected by three-dimensional time-of-flight magnetic resonance angiography. CONCLUSIONS: Anomalous origin of the OA from the anterior cerebral artery may be explained by a failure in the caudal migration of the ventral OA. Because of high soft tissue resolution and absence of radiation, three-dimensional time-of-flight magnetic resonance angiography is preferred for detection of orbital and cerebral vascular anomalies.

Avoiding blindness in managing epistaxis for a child with Duane's Retraction Syndrome.

Duane's Retraction Syndrome (DRS), a congenital cranial dysinnervation disorder, accounts for 5% of all strabismus. A vascular anomaly in DRS, which became clinically relevant in the context of significant epistaxis, is presented. A 15-year-old girl with DRS underwent a rhinological procedure for traumatic nasal deformity and suffered large volume epistaxis. Using angiography, an anatomical variation was identified, noting the ophthalmic artery was supplied by branches from the sphenopalatine artery, facial artery, and middle meningeal artery; not from the internal carotid artery. Hence epistaxis control was achieved via alternative methods, and unilateral blindness was avoided.

Unusual ophthalmic artery origin: Implications for intraarterial chemotherapy of retinoblastoma.

We report two pediatric retinoblastoma patients with unusual ophthalmic artery (OA) origins who were referred to our interventional neuroradiology department for intraarterial chemotherapy. The first patient had double OAs arising from the ipsilateral internal carotid artery and a central retinal artery (CRA) arising from the more cranially located artery, whereas the second patient had an OA originating from the A1 segment of the ipsilateral anterior cerebral artery. In both cases the CRA arose from the artery entering the orbit through the optic foramen. Both patients tolerated the procedures well. To the best of our knowledge, our retinoblastoma patients with unusual OA origins are the first in the literature in which detailed knowledge of the orbital vasculature and especially CRA origin carried immediate clinical implications, altering access strategies. These variations were proved both by flat-panel detector computed tomography findings and superselective injections of OAs with unusual origins. Our results show that in patients with retinoblastoma, a detailed angiographic work-up may be necessary to evaluate the orbital vasculature and possible abnormal origin of the OA. Recognition of possible variations of OA origin and its branching patterns is of the utmost importance for successful treatment and avoidance of adverse events among retinoblastoma patients.

Orbital Arteriovenous Fistula around the Optic Nerve Treated by Transvenous Embolization.

Intraorbital arteriovenous fistula (AVF) is a very rare disease; therefore an optimal treatment strategy has not yet been established. Here we describe the use of high-resolution cone-beam computed tomography (CBCT) and selective angiography to visualize the detailed anatomy of orbital vessels. The information provided by the intraoperative imaging led to a change in treatment strategy and eventually to successful transvenous coil embolization. A 55-year-old man presented with a 4 months history of right exophthalmos, chemosis and diplopia. Magnetic resonance (MR) imaging demonstrated a dilated superior orbital vein. Cerebral angiography showed an intraorbital AVF fed by the branch of the ophthalmic artery and drainage to the superior orbital vein (SOV) and inferior orbital vein (IOV). Superselective angiography and high-resolution CBCT with diluted contrast medium clarified that feeders of the AVF came from the first segment of the ophthalmic artery, and the shunt located surrounding an optic nerve sheath. Transvenous embolization via IOV with coils occluded the AVF. Detailed analysis of intraorbital vessels using high-resolution CBCT and selective angiography led to successful treatment by transvenous coil embolization.

Not the usual suspect.

An 82-year-old woman presented with right-sided proptosis, chemosis, and a supraorbital bruit. A dural carotid-cavernous fistula was suspected, but catheter angiography revealed an intraorbital inferior ophthalmic vein arteriovenous fistula supplied by the right ophthalmic artery and infraorbital branch of the internal maxillary artery. A primary orbital arteriovenous fistula can mimic the clinical and radiographic features of the more common carotid-cavernous fistula.

Incidental ethmoidal dural arteriovenous fistula coexisting with a pituitary adenoma exacerbating post-transsphenoidal epistaxis.

A 64 year-old man with pituitary adenoma developed massive epistaxis after an uneventful endoscopic transsphenoidal surgery. Angiography showed extravasation from the sphenopalatine artery, to which embolisation was performed. An incidentally coexisting ethmoidal dural arteriovenous fistula supplied by the ophthalmic artery aberrantly originated from the middle meningeal artery caused increased haemorrhage.

Orbital Arteriovenous Fistula Coexistent with an Arteriovenous Hemangioma: A Rare Occurrence and Review of Literature.

BACKGROUND: Orbital arteriovenous fistula (AVF) is a rare entity with only 17 cases reported so far. An arteriovenous hemangioma is a distinct entity of an angioma that most frequently affects the skin. However, to our knowledge, there has not been a case arising in the orbit. CASE DESCRIPTION: A previously healthy, 73-year-old man had progressive proptosis for 1 month. At presentation, the patient showed considerable proptosis, hyperemia in the lower eyelid, chemosis, and total ophthalmoplegia on the right side. Computed tomography and magnetic resonance imaging revealed a round retro-orbital mass, 23 mm in maximal dimension, and lying in the inferomedial aspect of the orbit with an irregular-shaped lesion in the orbital apex. Cerebral angiography detected an orbital AVF fed by the ipsilateral maxillary and ophthalmic arteries and draining into the inferior ophthalmic vein. Stain of the retro-orbital mass was not identified. A transvenous coil embolization via the facial and superior ophthalmic veins achieved complete isolation of the AVF with satisfactory outcome. Two months later, the orbital mass, well circumscribed and lacking perilesional hemosiderin deposition, was microsurgically resected via a lateral orbitotomy. Histological diagnosis was consistent with an arteriovenous hemangioma. CONCLUSIONS: An AVF and arteriovenous hemangioma may simultaneously develop in the same orbit. In patients with symptomatic orbital AVF and coexisting other orbital pathology, strategies should be carefully planned before setting about the treatment.

Imaging of Cerebral Arteriovenous Malformations and Arteriovenous Fistulas and Occlusion Control Using Intraoperative 3-Dimensional Rotational Fluoroscopy.

BACKGROUND: Intraoperative resection or occlusion control is indispensable in the surgery of vascular anomalies. This can be conducted using local vascular imaging modalities or angiographic techniques. This series was performed to assess whether cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulae (dAVFs) can be detected in a sufficient quality by intraoperative 3-dimensional (3D) fluoroscopy with intravenous contrast application. MATERIALS AND METHODS: Five patients were included in the analysis (2 AVMs, 3 dAVFs). All patients had preoperative digital subtraction angiography. The head was fixed in a carbon MAYFIELD clamp. After a 3D rotational fluoroscopy scan without contrast agent, a second scan with 50 mL of iodine contrast agent was performed. The Digital Imaging and Communications in Medicine data of both scans were subtracted and reconstructed using the OsiriX imaging software. In 2 patients with dAVF, occlusion control was performed after obliteration of the fistula. RESULTS: In the 2 patients with cerebral AVM, 3D fluoroscopy with intravenous contrast administration resulted in good image quality. Preoperative embolization with Onyx produces significant artifacts that can be largely removed by simple digital subtraction techniques. In dural AVF, occlusion control was well feasible after obliteration of the draining vein at its dural origin. CONCLUSIONS: This technique quickly supplies intraoperative images of adequate quality to locate cerebral AVM and dAVF. However, it does not produce dynamic images. Thus, early draining veins cannot be located unless anatomically identified based on the preoperative DSA. In this case, it can be used for intraoperative obliteration control.

The clinical presentation and collateral pathway development of congenital absence of the internal carotid artery.

OBJECTIVE: The objective of this study was to investigate the clinical presentation, risks, and collateral pathway development of the congenital absence of the internal carotid artery (ICA). METHODS: Sixty-four patients (10 new patients and 54 patients from the relevant literature) were studied. Data on demographic, clinical, and radiologic features were collected, followed by an analysis of the risks associated with ICA agenesis. RESULTS: There were 31 male and 33 female patients whose ages ranged from 5 months to 75 years, with a mean age of 31.1 years. The range of clinical symptoms recorded included transient ischemic attack (17 patients), subarachnoid hemorrhage (12 patients), developmental delay (13 patients), asymptomatic (8 patients), and other symptoms (15 patients). All 64 patients presented with absence of unilateral or bilateral ICAs, as measured by cervical computed tomography angiography or magnetic resonance angiography. The carotid canal was absent in all patients on computed tomography of the base of the skull, and abnormal development of collateral circulation pathways was observed. Five patients presented with basilar artery dilation on angiography. Aneurysms were observed in the angiography results from 16 patients. Ten patients presented with variations in the ophthalmic artery origin (the ophthalmic artery originated from the ipsilateral middle meningeal artery in six patients and from the ipsilateral middle cerebral artery in four patients). CONCLUSIONS: From analysis of our 10 cases of ICA agenesis and our review of the relevant literature, we conclude that young patients with ICA agenesis may present with developmental delay, subarachnoid hemorrhage, or other developmental abnormalities, whereas older patients most commonly present with transient neurologic events. Complications of carotid agenesis are related to specific anatomic subtypes and the resulting collateral circulation development.

Bilateral carotid-anterior cerebral artery anastomoses associated with bilateral ophthalmic arteries arising from the anastomotic arteries diagnosed by magnetic resonance angiography: a case report.

Rarely, the anterior cerebral artery (ACA) arises from the ophthalmic segment of the internal carotid artery, a condition described as carotid-ACA anastomosis or infraoptic course of the ACA that generally demonstrates right-sided predominance. We diagnosed a case of bilateral anastomoses of the carotid and ACA vessels in which bilateral ophthalmic arteries arose from the origins of the anastomotic vessels using magnetic resonance (MR) angiography. Identification of rare arterial variations on MR angiography requires careful scrutiny of source images, and creation of partial volume-rendering images can aid visualization of detailed anatomic structures.

Comprehensive Treatment of Primary Orbital Arteriovenous Malformation.

Primary orbital arteriovenous malformations are a rare kind of vascular malformation lesions. The authors present a 17-year-old man presented with swelling and pulsation in the left upper eyelid. The angiogram of the left internal carotid artery showed that arteriovenous malformations at the left upper eyelid area were supplied with one of the branches of ophthalmic artery. In this report, the authors elaborated the comprehensive treatments of primary arteriovenous malformation.

Immediate Reconstruction After Combined Embolization and Resection of Orbital Arteriovenous Malformation.

Orbital arteriovenous malformations are rare congenital vascular anomalies that can cause eyelid distortion, proptosis, diplopia, and vision loss. The current treatment paradigm involves endovascular embolization followed by resection, with delayed reconstruction. The authors report 2 young adult patients with orbital arteriovenous malformations, who underwent embolization followed days to months later by resection with immediate soft tissue reconstruction. For both patients, the immediate outcome provided good functionality and cosmesis. The authors conclude that immediate reconstruction after embolization-resection of orbital arteriovenous malformations may facilitate early return of form and function for patients, improve quality of life, and potentially reduce the need for further reconstructive procedures.