Visual pathway compromise after hydrocoil treatment of large ophthalmic aneurysms

OBJECTIVE: Hydrogel-coated coils (MicroVention, Inc., Aliso Viejo, CA) for endovascular aneurysm treatment offer the theoretical advantages of increased volumetric occlusion, thrombus stabilization, and improved neointimal healing. Reports of local inflammation and hydrocephalus after coiling of unruptured aneurysms have raised questions about the safety profile or appropriate usage of these new devices. CLINICAL PRESENTATION: Two patients with large ophthalmic aneurysms underwent elective endovascular coiling with HydroCoils. Three to 4 weeks later, they developed profound, progressive bilateral visual loss. Magnetic resonance imaging scans demonstrated extensive enhancement of the coil ball, surrounding brain parenchyma, and optic chiasm, with perianeurysmal edema. INTERVENTION: Dexamethasone produced impressive but temporary improvement in vision in one patient; the other experienced only minor improvement. One patient also developed hydrocephalus; ventriculoperitoneal shunting reduced ventricular size but had no effect on vision. Follow-up imaging demonstrated persistent enhancement of the coil ball, as well as recurrence and extension of the abnormal signal in the parenchyma and along the optic tract. CONCLUSION: Both patients have been left with no functional vision in the eye ipsilateral to the aneurysm and have experienced marked visual field loss and reduced acuity in the contralateral eye. Ongoing international studies will provide more information on the rate of inflammatory complications. The biological mechanisms underlying the phenomenon also require investigation. Meanwhile, we caution against using HydroCoils in situations in which worsened mass effect or local inflammation would have highly deleterious consequences, such as in large aneurysms adjacent to the visual pathways or the brainstem.