Acta Neurochirurgiea 33, 319--324 (1976) 9 by Springer-Verlag 1976
Depa.rtments of *Neurosurgery, **Ophthalmology and ***t/adiology, University of Brussels, Belgium
Spasm of the Ophthahnie Artery in a Case of Posttraumatic Amaurosis Case Report By
J. Brihaye*, M. Brihayc-Van 6ecrtruyden**, and L. Jeanmart*** With 5 Figures
Summary An extensive a.nd segmental spasm of the ophthalmic artery has been demonstrated angiographieally a few hours after a ear accident in a ease with posttraumatic amaurosis. The possibility of a eorrelation between ophthalmic artery spasm and posttraumatie amaurosis has been discussed. The various causes which have been reported as being responsible for posttraumatie amaurosis can be divided into two groups: those of a mechanical nature, which can include a simple contusion of the optic nerve, contusion with oedema and compression of the nerve in the bony canal, tearing of the nerve fibers by stretching or laceration by a jagged edge of bone; on rare occasions, eases of the optic nerve being secondarily compressed by callus have been described. The other group consists of causes of a vascular nature: a compressive hematoma in the sheaths of the optic nerve, tearing and thrombosis of the small parenchymal arteries of the nerve, and arterial angiospasm. According to the cause in question it is possible to explain immediate definitive amanrosis, immediate temporary amaurosis and partial delayed visual deficits. However, we must recognize that the verification and objectivation of these diverse etiologies is very rarely made: surgical opto-ehiasmatic exploration is most often negative; verification at autopsy is also rarely made and anatomico-elinical correlations are most commonly missing.
320
J. Brihaye
et a l . :
Fig. i. Fracture of the optic foramen
C o n s e q u e n t l y t h e various e x p l a n a t i o n s of p o s t t r a u m a t i c a m a u r o s i s r e m a i n h y p o t h e t i c a l in m o s t clinical cases.
Clinical Observation T h e case which we are r e p o r t i n g is no e x c e p t i o n to this rule, b u t yields i n f o r m a t i o n which we t h i n k is valid. I t concerns a 34 y e a r old m a n , i n j u r e d in a car a c c i d e n t on N o v e m b e r 1, 1974. Coma oecured i m m e d i a t e l y a n d d u r i n g t h e first e x a m i n a t i o n a left n o n r e a c t i v e m y d r i a s i s a n d a B~binski sign on t h e r i g h t side were observed. C o n s e q u e n t l y t h e p a t i e n t was t r a n s f e r r e d to our d e p a r t m e n t . W e e x a m i n e d t h e p a t i e n t a few hours after t h e accident. H e was
Spasm of the Ophthalmic Artery in a Ca,se of Posttraumatie Amaurosis 321
Fig. 2. Image of spasm of the ophthalmic artery limited to the region of the optic canal
Fig. 3. Same image b u t magnifieated
322
J. Brihaye
et a l . :
Fig. 4. I)isalopearance, seven days later, of the image of spasm of the ophthalmic artery. Small area of extravasation of the contrast media at the site of the optic foramen
in a state of agitated coma and already had a significant h e m a t o m a of the left orbital region, making examination of the eye difficult; Babinski sign persisted on the right side; X-rays of the skull showed a left frontoorbito-ethmoidal fracture and a fracture of the left optic foramen (Fig. 1). A left carotid arteriogram was immediately performed and demonstrated extensive and segmental spasm of the left ophthalmic artery, limited to the region of the bony optic canal (Figs. 2 and 3). The patient recovered from coma after 48 hours and the clinical improvement was rapid. A repeated left carotid angiogram was performed 7 days after the first one and the appearance of spasm of the left ophthalmic artery had disappeared but a small urea of extravasation of the contrast media could be seen at the site of the optic foramen and this extravasation could indicate injury to the arterial wall by a bone splinter. On the other hand the carotid syphon was slightly spastic whereas it was not on the first arteriogram (Figs. 4 and 5).
Spasm of the Ophthalmic Artery in a Case of Posttraumatic Amaurosis 323
Fig. 5. Same image but magnificated A surgical procedure was proposed in light of the fracture of the ethmoidal groove and the orbital roof. This was firstly refused but later accepted and was performed on December 4th. The operation consisted of a grafting of the ethmoi4 and restructuring of the orbital roof. The optic nerve had a normal appearance and size; it was not compressed in the optic foramen which was not opened surgically. The postoperative course was uneventful. Atrophy of the left optic nerve was observed five weeks after the accident and the amaurosis is considered to be permanent.
Discussion Arterial spasm in eranio-cerebral traumatology is a well known phenomenon and in general involves the carotid syphon (Vilato and L e B e a u , 1962; L. Symon, 1967; Snwanwela, 1972; McPherson and Graham, 1973, among other authors). To our knowledge, posttraumatie spasm of the ophthalmic artery has not been described. For a long time spasm of retinal arteries has been theorized as an explanation of the very transitory amaurosis in pathology of boxing
324
J. Brihaye et al. : Spasm of the Ophthalmic Artery
(Favory and Sedan, 1951). Let us recall in this matter the clinical, but at the same time almost experimental observation which was made by Sedan and Allies in 1951, of a rugby player who suffered an immediate blindness following a kick on the back of the neck. Examined 20 minutes later, vision remained extremely weak and fuzzy; the pupils were enlarged, photomotor reflexes hardly elieitable, retinal arteries extremely narrowed and the central retinal artery pressure hardly measurable while the brachial blood pressure was normal, if not slightly elevated. During the following hour, the vision progressively recovered and during this time the retinal arteries regained a normal diameter and the central retinal artery pressure rose to physiological values. This perfect correlation between visual function and the condition of the retinal arteries as well as the retinal arteries pressure has almost the same significance as an experimental observation, and such a clinical demonstration led us to think that spasm of the arteries of the optic nerve coulc[ play a major role in some cases of posttraumatic amaurosis. I t appears to us that our clinical observation, without being conclusive, draws the clinician's attention to the possible correlation in craniocerebral traumatology between ophthalmic artery spasm and posttraumatic amaurosis. References
Arseni, C., Maretsis, M., Horvath, L., Posttraumatic intraeranial arterial spasm: report of 3 cases. Acta l~eurochir. 24 (1971), 25--35. Favory, A., Sedan, J., Traumatologie oeulaire du boxeur. Arch. d'Ophtalm. 11 (1951), 429--456. MaePherson, P., Graham, D. I., Arterial spasm and slowing of the cerebral circulation in the ischaemia of head injury. J. :Neurol. Neurosurg. Psychiat. 36 (1973), 1069--1072. Sedan, J., Allies, P., ContrSle de la P. A. R. au cours m~me d'un knock-out. Revue d'O. N. O. 23 (1951), 374--377. Suwanwela, Ch., Suwanwela, :N., Intracranial arterial narrowing and spasm in acute head injury. J. ~eurosurg. 36 (1972), 3141323. Symon, L., An experimental study of traumatic cerebral vascular spasm. J. Neurol. ~eurosurg. Psyehiat. 30 (1967), 497--505. Vilato, 1%. J., Le Beau, J., Le spasme des art@res du cercle de Willis au tours des h6morragies traumatiques ou an6vrysmales. Iqeuro-Chirurgie 8 (1962), 217--221. Wilkins, 1%. H., Odom, G. L., Intracranial arterial spasm associated with cranio-cerebral trauma. J. l~eurosurg. 32 (1970), 626--633. Authors' address: Prof. Dr. J. Brihaye, Department o2 Ncurosurgery, Dr. M. Brihaye-van Geertruyden, Department of Ophthalmology, and Prof. Dr. L. Jeanmart, Department of 1%adiology, University of Brussels, 1, rue I-Idger-Bordet, B-1000 Brussels, Belgium.
Depa.rtments of *Neurosurgery, **Ophthalmology and ***t/adiology, University of Brussels, Belgium
Spasm of the Ophthahnie Artery in a Case of Posttraumatic Amaurosis Case Report By
J. Brihaye*, M. Brihayc-Van 6ecrtruyden**, and L. Jeanmart*** With 5 Figures
Summary An extensive a.nd segmental spasm of the ophthalmic artery has been demonstrated angiographieally a few hours after a ear accident in a ease with posttraumatic amaurosis. The possibility of a eorrelation between ophthalmic artery spasm and posttraumatie amaurosis has been discussed. The various causes which have been reported as being responsible for posttraumatie amaurosis can be divided into two groups: those of a mechanical nature, which can include a simple contusion of the optic nerve, contusion with oedema and compression of the nerve in the bony canal, tearing of the nerve fibers by stretching or laceration by a jagged edge of bone; on rare occasions, eases of the optic nerve being secondarily compressed by callus have been described. The other group consists of causes of a vascular nature: a compressive hematoma in the sheaths of the optic nerve, tearing and thrombosis of the small parenchymal arteries of the nerve, and arterial angiospasm. According to the cause in question it is possible to explain immediate definitive amanrosis, immediate temporary amaurosis and partial delayed visual deficits. However, we must recognize that the verification and objectivation of these diverse etiologies is very rarely made: surgical opto-ehiasmatic exploration is most often negative; verification at autopsy is also rarely made and anatomico-elinical correlations are most commonly missing.
320
J. Brihaye
et a l . :
Fig. i. Fracture of the optic foramen
C o n s e q u e n t l y t h e various e x p l a n a t i o n s of p o s t t r a u m a t i c a m a u r o s i s r e m a i n h y p o t h e t i c a l in m o s t clinical cases.
Clinical Observation T h e case which we are r e p o r t i n g is no e x c e p t i o n to this rule, b u t yields i n f o r m a t i o n which we t h i n k is valid. I t concerns a 34 y e a r old m a n , i n j u r e d in a car a c c i d e n t on N o v e m b e r 1, 1974. Coma oecured i m m e d i a t e l y a n d d u r i n g t h e first e x a m i n a t i o n a left n o n r e a c t i v e m y d r i a s i s a n d a B~binski sign on t h e r i g h t side were observed. C o n s e q u e n t l y t h e p a t i e n t was t r a n s f e r r e d to our d e p a r t m e n t . W e e x a m i n e d t h e p a t i e n t a few hours after t h e accident. H e was
Spasm of the Ophthalmic Artery in a Ca,se of Posttraumatie Amaurosis 321
Fig. 2. Image of spasm of the ophthalmic artery limited to the region of the optic canal
Fig. 3. Same image b u t magnifieated
322
J. Brihaye
et a l . :
Fig. 4. I)isalopearance, seven days later, of the image of spasm of the ophthalmic artery. Small area of extravasation of the contrast media at the site of the optic foramen
in a state of agitated coma and already had a significant h e m a t o m a of the left orbital region, making examination of the eye difficult; Babinski sign persisted on the right side; X-rays of the skull showed a left frontoorbito-ethmoidal fracture and a fracture of the left optic foramen (Fig. 1). A left carotid arteriogram was immediately performed and demonstrated extensive and segmental spasm of the left ophthalmic artery, limited to the region of the bony optic canal (Figs. 2 and 3). The patient recovered from coma after 48 hours and the clinical improvement was rapid. A repeated left carotid angiogram was performed 7 days after the first one and the appearance of spasm of the left ophthalmic artery had disappeared but a small urea of extravasation of the contrast media could be seen at the site of the optic foramen and this extravasation could indicate injury to the arterial wall by a bone splinter. On the other hand the carotid syphon was slightly spastic whereas it was not on the first arteriogram (Figs. 4 and 5).
Spasm of the Ophthalmic Artery in a Case of Posttraumatic Amaurosis 323
Fig. 5. Same image but magnificated A surgical procedure was proposed in light of the fracture of the ethmoidal groove and the orbital roof. This was firstly refused but later accepted and was performed on December 4th. The operation consisted of a grafting of the ethmoi4 and restructuring of the orbital roof. The optic nerve had a normal appearance and size; it was not compressed in the optic foramen which was not opened surgically. The postoperative course was uneventful. Atrophy of the left optic nerve was observed five weeks after the accident and the amaurosis is considered to be permanent.
Discussion Arterial spasm in eranio-cerebral traumatology is a well known phenomenon and in general involves the carotid syphon (Vilato and L e B e a u , 1962; L. Symon, 1967; Snwanwela, 1972; McPherson and Graham, 1973, among other authors). To our knowledge, posttraumatie spasm of the ophthalmic artery has not been described. For a long time spasm of retinal arteries has been theorized as an explanation of the very transitory amaurosis in pathology of boxing
324
J. Brihaye et al. : Spasm of the Ophthalmic Artery
(Favory and Sedan, 1951). Let us recall in this matter the clinical, but at the same time almost experimental observation which was made by Sedan and Allies in 1951, of a rugby player who suffered an immediate blindness following a kick on the back of the neck. Examined 20 minutes later, vision remained extremely weak and fuzzy; the pupils were enlarged, photomotor reflexes hardly elieitable, retinal arteries extremely narrowed and the central retinal artery pressure hardly measurable while the brachial blood pressure was normal, if not slightly elevated. During the following hour, the vision progressively recovered and during this time the retinal arteries regained a normal diameter and the central retinal artery pressure rose to physiological values. This perfect correlation between visual function and the condition of the retinal arteries as well as the retinal arteries pressure has almost the same significance as an experimental observation, and such a clinical demonstration led us to think that spasm of the arteries of the optic nerve coulc[ play a major role in some cases of posttraumatic amaurosis. I t appears to us that our clinical observation, without being conclusive, draws the clinician's attention to the possible correlation in craniocerebral traumatology between ophthalmic artery spasm and posttraumatic amaurosis. References
Arseni, C., Maretsis, M., Horvath, L., Posttraumatic intraeranial arterial spasm: report of 3 cases. Acta l~eurochir. 24 (1971), 25--35. Favory, A., Sedan, J., Traumatologie oeulaire du boxeur. Arch. d'Ophtalm. 11 (1951), 429--456. MaePherson, P., Graham, D. I., Arterial spasm and slowing of the cerebral circulation in the ischaemia of head injury. J. :Neurol. Neurosurg. Psychiat. 36 (1973), 1069--1072. Sedan, J., Allies, P., ContrSle de la P. A. R. au cours m~me d'un knock-out. Revue d'O. N. O. 23 (1951), 374--377. Suwanwela, Ch., Suwanwela, :N., Intracranial arterial narrowing and spasm in acute head injury. J. ~eurosurg. 36 (1972), 3141323. Symon, L., An experimental study of traumatic cerebral vascular spasm. J. Neurol. ~eurosurg. Psyehiat. 30 (1967), 497--505. Vilato, 1%. J., Le Beau, J., Le spasme des art@res du cercle de Willis au tours des h6morragies traumatiques ou an6vrysmales. Iqeuro-Chirurgie 8 (1962), 217--221. Wilkins, 1%. H., Odom, G. L., Intracranial arterial spasm associated with cranio-cerebral trauma. J. l~eurosurg. 32 (1970), 626--633. Authors' address: Prof. Dr. J. Brihaye, Department o2 Ncurosurgery, Dr. M. Brihaye-van Geertruyden, Department of Ophthalmology, and Prof. Dr. L. Jeanmart, Department of 1%adiology, University of Brussels, 1, rue I-Idger-Bordet, B-1000 Brussels, Belgium.
