Ophthalmic artery pseudoaneurysm

Key points at a glance

Key points of this condition

• Ophthalmic artery pseudoaneurysm (OAPA) is a rare vascular lesion that occurs after high-energy trauma or iatrogenic injury.
• Unlike a true aneurysm, blood leaking from a defect in the vessel wall forms a false lumen.
• A pulsatile mass around the orbit is the most suggestive clinical finding.
• For diagnosis, initial evaluation with CT/CTA is followed by DSA, which is the most reliable confirmatory test.
• The first-line treatment is endovascular coil embolization, and the literature reports a fairly high success rate.
• Because of its proximity to the central retinal artery, there is a risk of permanent vision loss even with endovascular treatment.
• This is a rare disease, with only about 15 reported cases in the literature from 2005 to 2025.

1. What is an ophthalmic artery pseudoaneurysm

A pseudoaneurysm of the ophthalmic artery (Ophthalmic Artery Pseudoaneurysm; OAPA) is a rare vascular lesion in which a pseudoaneurysm forms in the ophthalmic artery.

A true aneurysm enlarges while preserving the vessel wall’s three-layer structure, whereas a pseudoaneurysm occurs when there is a defect in the vessel wall, and blood leaking from it remains in the outer layer of the vessel wall or surrounding soft tissue to form a false lumen. Because the bony orbit and the surrounding orbital fat usually protect the ophthalmic artery, direct injury to it is uncommon. However, the risk rises sharply when there is direct trauma to the orbit or an intervention such as surgery.

Ophthalmic artery pseudoaneurysm is a condition that can threaten both vision and life, and it is characterized by rapid onset. In the literature, only about 15 case reports have been described from 2005 to 2025.

Q How is an ophthalmic artery pseudoaneurysm different from a true aneurysm?

A

A true aneurysm enlarges while preserving the vessel wall’s three-layer structure. A pseudoaneurysm differs fundamentally because blood leaks from a defect in the vessel wall and forms a false lumen held in the outer layer of the vessel wall or surrounding soft tissue. Because it is not contained by the vessel wall, the risk of rupture and rapid enlargement is higher.

2. Main symptoms and clinical findings

Subjective symptoms

Patients with ophthalmic artery pseudoaneurysm often seek care after acute trauma, and they may not be able to describe their medical history accurately.

• Decreased vision: Occurs with increased intraocular pressure or retinal ischemia.

Clinical findings (findings confirmed by the doctor on examination)

• Pulsatile orbital mass (pulsatile mass): The most suggestive sign of pseudoaneurysm formation. It appears as a mass with palpable pulsation around the orbit. Pulsatile proptosis with a bruit strongly suggests a vascular lesion.
• Eye bulging (proptosis): occurs as orbital volume increases.
• Conjunctival swelling (chemosis): swelling of the conjunctiva.
• Subconjunctival hemorrhage: bleeding associated with trauma or vascular lesions.
• Increased eye pressure: may rise rapidly due to enlargement of the pseudoaneurysm or associated retrobulbar hemorrhage.

Q What should be suspected when there is a pulsating swelling around the orbit?

A

A pulsating orbital mass is the most suggestive sign of ophthalmic artery pseudoaneurysm formation. If this finding is seen in a patient with a history of trauma or surgery, imaging (CT/CTA) should be performed promptly to confirm the presence of a vascular lesion.

3. Causes and risk factors

Ophthalmic artery pseudoaneurysm usually occurs on one side. It may be bilateral when high-energy trauma affects both orbits. The shearing force during trauma damages the vessel wall and creates a false lumen.

Blunt trauma

Assault or violence: direct blunt force to the orbit from a fist or similar.

Traffic accident: head contusion, airbag deployment, whiplash.

Fall: impact to the head or orbit.

Penetrating injury

Penetrating wound from flying objects: direct force into the orbit from bullets, knives, and similar objects.

Iatrogenic and other causes

Surgery: vascular injury from oculoplastic surgery, otolaryngology surgery, or skull base surgery.

Procedure-related: cases of persistent nosebleeds after nasogastric tube (NG tube) placement have been reported.

Inflammation and infection: history of eye infection, cellulitis, or arteriovenous fistula.

Systemic factors that increase risk include anticoagulant therapy and the use of antiplatelet or antithrombotic drugs (for diabetes or cardiovascular disease).

Expert note

In patients with a history of eye infection, cellulitis, or arteriovenous fistula, the risk of pseudoaneurysm formation after trauma is higher. Be aware that it can occur even after minor trauma in patients receiving anticoagulant therapy.

4. Diagnosis and testing

Diagnosing an ophthalmic artery pseudoaneurysm requires a comprehensive approach that includes clinical evaluation, detailed eye examination, radiologic imaging, and, when needed, interventional procedures.

The features of each imaging method are shown below.

Examination method	Role	Features
CT/CTA	Initial evaluation	Allows rapid assessment of intracranial bleeding, bone structures, and vascular lesions
MRI/MRA/MRV	Confirmation and follow-up	Useful for confirming the diagnosis and identifying the source of the lesion
DSA	Definitive diagnosis and treatment	Most reliable, but also the most invasive. Can serve as both diagnosis and treatment

• Head CT and CTA (initial evaluation): Non-contrast head CT and CTA identify intracranial hemorrhage and vascular lesions. A pseudoaneurysm may rapidly enlarge in the early stage and can resemble a hematoma. The exact timing of progression may not become clearly visible until as late as 24 hours after the initial injury. As a distinction from hematoma, a pseudoaneurysm remains stable in size if there is no active contrast leak. CT is also excellent for evaluating bony structures and has the advantage of being easy to perform in emergencies.
• MRI, MRA, and MRV (advanced imaging): Useful for confirmatory diagnosis during follow-up. Excellent for identifying the source of the lesion.
• Digital subtraction angiography (DSA): The most definitive diagnostic method. It can visualize the size and hemodynamics of a pseudoaneurysm in real time. Because diagnosis and treatment (coil embolization) can be done in the same session, it is invasive but allows a smooth transition to treatment after diagnosis is confirmed.
• Dilated fundus examination: After confirming with the neurosurgery and neuro-ICU teams that dilation is possible, perform it early. It is important for checking for retinal hemorrhage and ischemic injury.

Q How are a pseudoaneurysm and a hematoma distinguished?

A

On CTA, a pseudoaneurysm tends to remain stable in size if there is no active contrast leak. A hematoma differs in that it can enlarge over time. If there is any uncertainty, further evaluation with MRI/MRA or DSA is needed.

5. Standard treatments

Endovascular treatment (first-line)

Endovascular coil embolization: A microcatheter is advanced near the pseudoaneurysm, and an embolic coil or glue is delivered. Completion is confirmed with angiography after the procedure. A fairly high success rate has been reported in the literature¹². Partial embolization aimed at preserving the ophthalmic artery is also an option².

Endovascular balloon embolization: This may be attempted when the lesion is near the origin of the internal carotid artery (mainly a pre-coil-era technique).

Flow diverter (FD) stent: FD placement has been reported for subarachnoid hemorrhage caused by ophthalmic artery injury³.

NBCA glue injection: There are reports of its use for persistent epistaxis and peripheral lesions⁴.

Surgical treatment

Transcranial orbital approach: Performed in one case in China. After blunt trauma, the pseudoaneurysm was successfully removed with a right transcranial orbital approach plus orbital decompression, but postoperative vision was no light perception (NLP) and complete ophthalmoplegia.

Extradural approach: Performed in one case in Japan. After closed head injury from a traffic accident, resection was successful via an extradural approach, and postoperative vision was NLP.

Only two reports of surgical resection have been published.

Conservative management

Multidisciplinary follow-up: One case of spontaneous thrombosis was reported under coordinated care by ophthalmology, neurointerventional, and neurocritical care teams (UMass Memorial: spontaneous thrombosis was confirmed on serial CTA 72 hours later).

If the proximal ophthalmic artery is occluded, branches of the external carotid artery may provide collateral circulation via anastomoses with the orbital branches of the ophthalmic artery. However, there is also a risk of permanent vision loss.

Treatment considerations

Because the ophthalmic artery is close to the origin of the central retinal artery, embolization may carry a risk of permanent vision loss. Before treatment, thorough informed consent with the patient is essential.

Q Can endovascular treatment cause vision loss?

A

Because the ophthalmic artery is close to the origin of the central retinal artery, embolization may carry a risk of permanent vision loss. In the two surgical resection cases, both patients had no light perception (NLP) after surgery, so it is important to discuss visual prognosis with the patient before treatment.

6. Pathophysiology and detailed mechanism of onset

A true aneurysm enlarges while preserving the three-layer structure of the vessel wall: the intima, media, and adventitia. A pseudoaneurysm differs from this: blood leaks through a defect in the arterial wall and forms a false cavity contained by the adventitia or surrounding soft tissue.

The mechanism of onset due to trauma is as follows.

• Shearing force on the vessel wall (shearing force): High-energy trauma directly injures the ophthalmic artery wall, causing a defect in the vessel wall.
• Breakdown of the eye socket’s protective mechanism: Normally, the bony orbital wall and orbital fat protect the ophthalmic artery, but with direct orbital trauma, this protective mechanism no longer functions.
• Formation and expansion of the false cavity: The leaked blood remains in the adventitia and forms a false cavity. Over time, it enlarges and causes increased intraocular pressure and compression of the optic nerve and retina.
• Risk of rupture: If left untreated, it may rupture and lead to intracranial bleeding and hematoma formation. A pseudoaneurysm that passes through the dura may cause subarachnoid hemorrhage if untreated, and the risk of rebleeding is high ¹³.
• Delayed onset: Even if angiography immediately after injury is negative, the aneurysm may become apparent over several days to two weeks, so follow-up imaging is recommended ⁵².

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7. Latest Research and Future Outlook (reports at the research stage)

For patients: please read carefully

The following content is still at the research stage or under clinical investigation and is not standard treatment available at ordinary hospitals. It is reference information for specialists about future medical developments.

Ophthalmic artery pseudoaneurysm is an extremely rare condition with evidence limited to case reports, and knowledge is still being accumulated in the following areas.

Potential for conservative management: There are reports of spontaneous embolization (UMass Memorial 2023, Gu et al. 2025). This is only possible under close follow-up by a multidisciplinary team, and it is not yet a stage where waiting for the natural course can be generalized.

Innovation in embolic materials: In addition to coil embolization, use of NBCA glue (25%) and liquid embolic materials has been reported, and optimization of material selection according to lesion location and shape is being explored.

The 15 cases in the literature are organized by treatment method as follows.

Treatment method	Main outcome
Endovascular coil embolization	Most frequently reported. Relatively high success rate
Surgical resection	Only 2 cases. Both were NLP after surgery
Conservative management	Spontaneous embolization confirmed after 72 hours in one case

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8. References

Footnotes

1. Hopkins JK, Shaibani A, Ali S, et al. Coil embolization of posttraumatic pseudoaneurysm of the ophthalmic artery causing subarachnoid hemorrhage. Case report. J Neurosurg. 2007;107(5):1043-1046. doi:10.3171/JNS-07/11/1043. PMID: 17977280 ↩ ↩²

2. Shim YS. Coil embolization of traumatic ophthalmic artery aneurysm: case report. Korean J Neurotrauma. 2022;18(1):98-102. doi:10.13004/kjnt.2022.18.e2. PMID: 35557629 ↩ ↩² ↩³

3. Veldeman M, Ridwan H, Hasan D, Rieg A, Clusmann H, Schubert GA. Ocular trauma with ophthalmic artery injury as a rare cause of subarachnoid hemorrhage: a case report and review of the literature. J Neurol Surg A Cent Eur Neurosurg. 2023;84(3):281-284. doi:10.1055/s-0041-1725956. PMID: 34100268 ↩ ↩²

4. Chun HJ, Yi HJ. Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: case report. Surg Neurol. 2009;71(6):701-704. doi:10.1016/j.surneu.2007.11.018. PMID: 18313737 ↩

5. Kikkawa Y, Natori Y, Sasaki T. Delayed post-traumatic pseudoaneurysmal formation of the intracranial ophthalmic artery after closed head injury. Case report. Neurol Med Chir (Tokyo). 2012;52(1):41-43. doi:10.2176/nmc.52.41. PMID: 22278026 ↩