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Quick Case

Giant Intracranial Aneurysms Threaten Woman’s Vision and Life

During an 8-month period, a 48-year-old woman who was losing her vision had repeated consultations with her local optometrist to optimize her prescription for bifocal contact lenses. When her vision continued to deteriorate, she went to a new optometrist who concluded that, given that standard eye examination failed to reveal the cause of her vision loss, the source might instead be neurologic. He referred her to a neurologist.

Findings on magnetic resonance imaging (MRI) revealed 2 giant aneurysms compressing her optic nerves, threatening not only her vision but also her life (Figure 1). A local cerebrovascular surgeon suggested she undergo endovascular coiling to slowly divert blood flow from the aneurysm, effectively sealing off the aneurysm over time. The patient sought a second opinion and was directed to the Duke Cerebrovascular and Skull Base Center.

Duke neurosurgeon Ali Zomorodi, MD, and neurosurgery physician assistant Lazaro Gonzales, PA-C, assessed the patient’s situation: Because of the size and location of her bilateral aneurysms, direct surgical clipping to occlude the aneurysms presented unique and complex considerations. However, endovascular flow diversion with a stent, though likely to successfully treat the aneurysms, would lead them to initially swell and compress the optic nerves, causing the patient to permanently lose her vision.

Question: What procedure did the clinicians recommend as having the best chance of treating the aneurysms while preserving the patient’s vision?

FIGURE 1: Initial angiograms of the cerebral aneurysms in the patient.

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