Case Report Visual Loss, Homonymous Hemianopia, and ...downloads.hindawi.com/journals/criopm/2013/562397.pdf · Vertebrobasilar Dolichoectasia PanteleimonMortzos 1 andTorbenLykkeSørensen

Hindawi Publishing CorporationCase Reports in Ophthalmological MedicineVolume 2013, Article ID 562397, 3 pageshttp://dx.doi.org/10.1155/2013/562397

Case ReportVisual Loss, Homonymous Hemianopia, andUnilateral Optic Neuropathy as the Presenting Symptoms ofVertebrobasilar Dolichoectasia

Panteleimon Mortzos1 and Torben Lykke Sørensen1,2

1 Department of Ophthalmology, Copenhagen University Hospital Roskilde, 4000 Roskilde, Denmark2 Faculty of Health Sciences, University of Copenhagen, 2200 Copenhagen, Denmark

Correspondence should be addressed to Panteleimon Mortzos; [email protected]

Received 5 March 2013; Accepted 9 April 2013

Academic Editors: A. A. Bialasiewicz and G. Kleinmann

Copyright © 2013 P. Mortzos and T. L. Sørensen.This is an open access article distributed under theCreativeCommonsAttributionLicense, which permits unrestricted use, distribution, and reproduction in anymedium, provided the originalwork is properly cited.

Vertebrobasilar dolichoectasia (VBD) is a relatively rare disorder for which unfortunately there is no treatment. Here we describe acase of simultaneous pre- and postchiasmal visual pathway pathology secondary to a space occupying VBD. In addition our patientdemonstrates one of the very few cases of VBD compression of the retrochiasmal pathway with no other cranial nerve involvement.

1. Introduction

Dolichoectasia refers to a diffuse dilatation of an artery(differentiating it from aneurysms) as well as marked elon-gation and tortuosity of the vessel. Intracranially, the mostcommonly affected area is the vertebrobasilar segment withcarotid and middle cerebral artery ectasia occurring lessoften.

Although vertebrobasilar dolichoectasia (VBD) is fre-quently asymptomatic, presenting symptoms vary frombeingsecondary to ischemia, compression, or rarely vascular rup-ture [1, 2].

VBD has been described to cause ophthalmologicalsymptoms, by direct compression of cranial nerves such asthe trigeminal and facial and less frequently the abducensand oculomotor nerves [3, 4]. In addition, rare cases of directcompression by aVBDof the optic tract or the chiasm causingvisual loss have also been previously reported [5, 6].

Here, we report a patient with right homonymous hemi-anopia due to direct compression by the ectatic basilarartery on the left optic track and compressive left opticneuropathy by secondary displacement of the adjacent leftinternal carotid artery.

2. Case Presentation

A 71-year-old man presented with gradual, progressive, andbilateral visual loss and reading difficulties over the last 6months. His medical history was unremarkable, and he hadno other symptoms apart from failing vision. He had noprevious ophthalmic history apart frommoderate amblyopiaon the right eye (RE). The best corrected visual acuities were20/40 RE and 20/100 left eye (LE), respectively. Automatedrefraction revealed anisometropic myopia of −5,25 sph REand −3,75 sph LE.

On Ishihara colour test the patient identified 15/15 plateson the RE and 13/15 plates on the LE. Pupils were equal andnormally reactive to light and near stimuli.There was no signof a relative afferent pupillary defect (RAPD). Ocularmotilityand remaining cranial nerve examination was normal. Opticdisc evaluation showed normal discs, central cupping of 0.4,with myopic peripapillary chorioretinal atrophy and a slighttilt of the right disc.

Humphrey perimetry 30-2 revealed a dense right homon-ymous hemianopia with constriction of the remaining lefthemifield in the LE (Figure 1).

Magnetic resonance imaging revealed a dilated right ver-tebral artery which continued as a severely ectatic (up to

2 Case Reports in Ophthalmological Medicine

LE

0 3 ⟨0 ⟨0

⟨0 6 0 ⟨0 1 ⟨0

6 9 7 14 ⟨0 5 5 ⟨0

8 14 23 20 25 6 13 7 0 ⟨0

7 16 14 19 26 4 13 12 4 73030

⟨0 15 25 27 4 9 5 ⟨0 ⟨0

⟨0 15 14 24 25 ⟨0 0 10 ⟨0 ⟨0

0 15 28 19 ⟨0 2 0 ⟨0

⟨0 10 11 ⟨0 ⟨0 ⟨0

⟨0 10 ⟨0 ⟨0

⟨0Δ

(a)

RE

11 8 2 ⟨0

⟨0

⟨0

⟨0

19 22 14 6 5 ⟨0

⟨021 24 26 25 6 2 ⟨0

⟨0

⟨0

⟨0

⟨0

⟨0⟨015 21 27 29 27 10 5 ⟨0

21 27 28 30 28 5 0 0

03030

21 27 30 31 28 ⟨0

12 24 28 31 31 ⟨0

⟨0

0 ⟨0

9 26 25 28 ⟨0 ⟨0

18 25 24 ⟨0 ⟨0 ⟨0

15 18 ⟨0 ⟨0

⟨0Δ

(b)

Figure 1: Visual field testing Humphrey 30-2. Left eye (LE) and right eye (RE), showing a right homonymous hemianopia with constrictionof the remaining left hemifield on the LE.

Figure 2: Magnetic resonance imaging (T2-weighted axial view). Ectatic basilar artery trunk compressing on the pons and the retrochiasmalpathway (black arrow depicting lumen of the basilar artery). Note the displaced internal carotid artery adjacent to the left optic nerve (whitearrow).

(a) (b)

Figure 3: Magnetic resonance imaging (T1-weighted, contrast-enhanced). (a) Midline sagittal view (white arrow depicting dolichoectaticbasilar artery elevating the floor of lateral ventricle). Note mass-effect on the brainstem. (b) Marked elevation of left optic tract (white arrow).

Case Reports in Ophthalmological Medicine 3

1.5 cm) and elongated basilar artery with direct compressionon the left optic tract. Those findings were diagnostic forVBD. There was mass-effect displacement of the left internalcarotid artery which compressed the left optic nerve (Figures2 and 3).

3. Discussion

To our knowledge, this is the first reported case of simulta-neous pre- and postchiasmal visual pathway pathology sec-ondary to a space occupying VBD. Our patient demonstratesone of the very few cases of VBD compression of the retrochi-asmal pathway with no other cranial nerve involvement. Inaddition, due to the ectasiasmass-effect, there is displacementof the left internal carotic artery, compressing the left opticnerve. We suggest that an expected RAPD of the left pupil iscancelled out by the simultaneously occurring RAPD of theright eye which is a consequence of the left optic tract lesion.

VBD is a radiological diagnosis. The normal meandiameter of a basilar artery is 3.17mm. Generally, ectasiais diagnosed if the diameter is over 4.5mm [1, 7]. Theseverity of VBD depends on the calibre, the length, andtortuosity of the artery. The basilar artery and its bifurcationare located deep in the center of the cranial base withclose proximity to central neurovascular structures. Posteriorcirculation ischemia, intracranial haemorrhage, and directcompression are the main risk factors to higher morbidityand mortality [7]. The most common long-term compli-cations of dolichoectasia are ischemic stroke, brainstemcompression, transient ischemic attack, hemorrhagic stroke,hydrocephalus, and subarachnoid hemorrhage [2]. The five-year mortality is approximately 30% [2].

Our patient remains free of any other neurologicalsymptoms to this date. As surgical management is notrecommended, his condition remains untreatable.

References

[1] M. Lou and L. R. Caplan, “Vertebrobasilar dilatative arteri-opathy (dolichoectasia),” Annals of the New York Academy ofSciences, vol. 1184, pp. 121–133, 2010.

[2] F. J.Wolters, G. J. Rinkel, andM.D. Vergouwen, “Clinical courseand treatment of vertebrobasilar dolichoectasia: a systematicreview of the literature,”Neurological Research, vol. 35, no. 2, pp.131–137, 2013.

[3] N. Goldenberg-Cohen and N. R. Miller, “Noninvasive neu-roimaging of basilar artery dolichoectasia in a patient with anisolated abducens nerve paresis,” American Journal of Ophthal-mology, vol. 137, no. 2, pp. 365–367, 2004.

[4] M. Hashimoto, K. Ohtsuka, H. Akiba, and K. Harada, “Vascularcompression of the oculomotor nerve disclosed by thin-slicemagnetic resonance imaging,”American Journal of Ophthalmol-ogy, vol. 125, no. 6, pp. 881–882, 1998.

[5] V. Purvin, A. Kawasaki, and S. Zeldes, “Dolichoectatic arterialcompression of the anterior visual pathways: neuro-ophthalmicfeatures and clinical course,” Journal of Neurology, Neurosurgeryand Psychiatry, vol. 75, no. 1, pp. 27–32, 2004.

[6] M. F. Guirgis, B. L. Lam, and S. F. Falcone, “Optic tract com-pression from dolichoectatic basilar artery,” American Journalof Ophthalmology, vol. 132, no. 2, pp. 283–286, 2001.

[7] E. E. Ubogu and O. O. Zaidat, “Vertebrobasilar dolichoectasiadiagnosed by magnetic resonance angiography and risk ofstroke and death: a cohort study,” Journal of Neurology, Neuro-surgery and Psychiatry, vol. 75, no. 1, pp. 22–26, 2004.

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Documents

Case Report Visual Loss, Homonymous Hemianopia, and ...downloads.hindawi.com/journals/criopm/2013/562397.pdf · Vertebrobasilar Dolichoectasia PanteleimonMortzos 1 andTorbenLykkeSørensen