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Isolated giant internal carotid artery aneurysm presenting as strabismus and vision loss in a young child

1 Department of Pediatric Ophthalmology, Strabismus and Neuro-ophthalmology, Aditya Birla Sankara Nethralaya, (A Unit of Medical Research Foundation, Chennai), Kolkata, West Bengal, India
2 Orbit, Oculoplasty, Reconstructive & Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata, India, (A Unit of Medical Research Foundation, Chennai, India), Kolkata, West Bengal, India
3 Department of Radiodiagnosis, EKO X ray and Imaging Institute, 54, Jawahar Lal Nehru Road, Kolkata, West Bengal, India

Date of Submission02-Jun-2021
Date of Decision29-Mar-2022
Date of Acceptance23-Jul-2022
Date of Web Publication12-Dec-2022

Correspondence Address:
Sweksha Priya,
Department of Pediatric Ophthalmology, Strabismus and Neuro-ophthalmology, Aditya Birla Sankara Nethralaya, (A Unit of Medical Research Foundation, Chennai), Kolkata - 700 099, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_170_21


Keywords: Internal carotid artery aneurysm, intracranial aneurysm, optic atrophy, vision loss

How to cite this URL:
Mittal S, Priya S, Alam MS, Guha S, Kundu S. Isolated giant internal carotid artery aneurysm presenting as strabismus and vision loss in a young child. Oman J Ophthalmol [Epub ahead of print] [cited 2023 Jan 28]. Available from: https://www.ojoonline.org/preprintarticle.asp?id=363274

   Introduction Top

Intracranial aneurysm is a rare but devastating condition in the pediatric age group. Although 13% of these cases are associated with a decrease in vision and field changes,[1] isolated profound loss of vision is quite rare. To the best of the authors' knowledge, there are only three case reports of pediatric intracranial aneurysms with loss of vision, reported in the literature.[2],[3],[4] We hereby report a rare case of isolated giant aneurysm of the internal carotid artery (ICA) presenting as strabismus and vision loss in a young boy.

   Case Report Top

An 11-year-old male child was brought to the clinic with complaints of outward deviation and loss of vision in the right eye for the past 6 months. There was no history of trauma or any other systemic complaints. On examination, his best-corrected visual acuity in the right eye was counting fingers at 2 m, whereas it was 20/20 in the left eye. The right eye had a Grade 3 relative afferent pupillary defect. Intraocular pressure was normal. The child was unable to read the test plate of the Ishihara chart with the right eye, whereas color vision was normal in the left eye. There were 30 prism diopters exotropia by the Modified Krimsky test. Fundus examination revealed a pale optic disc in the right eye [Figure 1]a, whereas it was normal in the left [Figure 1]b. Humphrey visual field examination showed a severely constricted field in the right eye [Figure 2]a and a normal field in the left eye [Figure 2]b.
Figure 1: Color fundus photo showing optic disc pallor in the right eye (a) and normal-looking disc in the left eye (b)

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Figure 2: Humphrey visual field 24-2 showing normal field in the left eye (a) and constricted field in the right eye (b)

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The child was advised magnetic resonance imaging (MRI) of the brain and orbits which showed unruptured saccular aneurysm (3.0 cm × 2.3 cm × 2.3 cm) arising from the supraclinoid part of the right ICA [Figure 3]a. There was compression of the intracranial prechiasmatic portion of the right optic nerve and it was poorly delineated on the MRI scan [Figure 3]b. The child was immediately referred to an interventional radiologist and he underwent balloon occlusion and coiling of the aneurysm.
Figure 3: Magnetic resonance angiography showing an aneurysm arising from the supraclinoid part of the right ICA (a) (red arrow). Magnetic resonance imaging coronal section showing giant aneurysm of the right ICA (blue arrow) causing marked compression of the right prechiasmal optic nerve and well-delineated prechiasmal optic nerve on the left side (b) (red arrow). ICA: Internal carotid artery

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   Discussion Top

The incidence rate of cerebral aneurysms in children is reported to be around 1%–2% of all intracranial aneurysms.[2] Aneurysms in children tend to be larger and are more likely to be located in the posterior circulation as compared to adults.[2] Intracranial aneurysms can cause devastating damage by compression, thrombosis, or rupture. While subarachnoid hemorrhage is the most common presentation in such cases, the mass effect of the lesion causing optic atrophy and consequent sensory strabismus led to an earlier diagnosis of this otherwise lethal condition in this particular case.

Vision loss in intracranial aneurysms can occur from compression in the visual pathway.[5] Although parachiasmal compression in children is commonly due to pituitary tumors or gliomas, this case demonstrates the rare occurrence of ICA aneurysm causing parachiasmal optic nerve compression.

Another notable feature, in this case, was the presence of unilateral field loss, despite the proximity of the aneurysm to the optic chiasma. On clinical correlation, we feel that the aneurysm was mainly displacing the chiasma and not really deforming it so the field defect on the contralateral side was not found.

   Conclusion Top

This case highlights the importance of suspecting serious intracranial pathology in a child with unexplained vision loss. There should be a low threshold for neuroimaging in all such cases. Timely intervention can avoid potentially life-threatening situations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hetts SW, Narvid J, Sanai N, Lawton MT, Gupta N, Fullerton HJ, et al. Intracranial aneurysms in childhood: 27-year single-institution experience. AJNR Am J Neuroradiol 2009;30:1315-24.  Back to cited text no. 1
Dörfler A, Wanke I, Wiedemayer H, Weber J, Forsting M. Endovascular treatment of a giant aneurysm of the internal carotid artery in a child with visual loss: Case report. Neuropediatrics 2000;31:151-4.  Back to cited text no. 2
Rush JA, Balis GA, Drake CG. Bitemporal hemianopsia in basilar artery aneurysm. J Clin Neuroophthalmol 1981;1:129-33.  Back to cited text no. 3
Brandner M, Lindner S, Langmann A. Sudden visual loss in a 7-year old patient. Ophthalmologe 2009;106:252-5.  Back to cited text no. 4
Date I, Asari S, Ohmoto T. Cerebral aneurysms causing visual symptoms: Their features and surgical outcome. Clin Neurol Neurosurg 1998;100:259-67.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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