Supraorbital craniotomy for microvascular decompression of optic nerve due to neurovascular conflict with anterior cerebral artery: 2-Dimensional operative video

Optic neuropathy due to vascular compression is a rare and poorly understood phenomenon. While contact between the optic nerve and nearby arteries is not uncommon, in most cases, it is an incidental finding in asymptomatic patients. Vascular compression has previously been suggested to be associated with optic neuropathy and visual dysfunction, with a plausible role for surgical decompression in appropriately selected patients.^2–5 We present the case of a 63-year-old male who presented with eight years of progressive left optic neuropathy with worsening binocular diplopia, visual field deficits, depth perception, and color vision. Left-sided fundus exam demonstrated diffuse pallor. Imaging demonstrated atrophy of the left optic nerve with compression by the A1 segment of the anterior cerebral artery. Extensive neuro-ophthalmology workup did not reveal other conceivable causes for his presentation. The patient underwent a left supraorbital craniotomy for microvascular decompression through an eyebrow incision, during which the left A1 was found to be compressing the left optic nerve. The artery was released and the nerve decompressed using felt pledgets. Postoperatively, the patient experienced subjective and objective improvement in visual acuity. Our case suggests that patients with progressive optic neuropathy, radiographic evidence of vascular compression, and no alternative cause for visual dysfunction should be carefully evaluated for consideration of microvascular decompression.