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European Journal of Ophthalmology Nov 2020The changes in the cardiovascular system are associated with ocular manifestations, often as a consequence of pathological alteration in the ocular vasculature. The ease... (Review)
Review
The changes in the cardiovascular system are associated with ocular manifestations, often as a consequence of pathological alteration in the ocular vasculature. The ease of visualization of these retinal changes makes the eye a window to the cardiovascular system. Certain congenital cardiac defects lead to changes in the retinal vascularity due to increased tortuosity and dilatation. In adults, the arterial dissection of internal carotid and vertebral arteries present as amaurosis fugax with or without oculo-sympathetic palsy. The patients with untreated infective endocarditis present with Roth spots, retinitis, embolic retinopathy, or sub-retinal abscesses. Hypoperfusive, hypertensive, or "mixed" retinopathy is a hallmark sign in patients of untreated infective endocarditis. Giant cell arteritis can present with ischemic ocular symptoms that may precipitate in irreversible vision loss. Systemic vascular manifestations such as coronary artery disease may manifest in a wide range of symptoms from amaurosis fugax to vision loss depending upon the size and location of retinal emboli. Rare cardio-oncological pathologies such as myxomas result in vision loss secondary to central retinal artery occlusion. A high clinical suspicion in patients with history of cardiovascular diseases can help in early diagnosis and management of impending, adverse cardiovascular and cerebrovascular events. In this review, we comprehensively discuss the spectrum of cardiac and vascular diseases with ocular manifestations as well as highlight the typical ocular presentations associated with these pathologies.
Topics: Cardiovascular Diseases; Cardiovascular System; Humans; Retinal Diseases
PubMed: 32340480
DOI: 10.1177/1120672120914232 -
Mayo Clinic Proceedings Feb 2019To determine the risk of ischemic stroke, transient ischemic attack (TIA), and amaurosis fugax around the time of central retinal artery occlusion (CRAO).
OBJECTIVE
To determine the risk of ischemic stroke, transient ischemic attack (TIA), and amaurosis fugax around the time of central retinal artery occlusion (CRAO).
PATIENTS AND METHODS
Patients at Mayo Clinic sites with a diagnosis code of CRAO from January 1, 2001, through September 9, 2016, were reviewed. New CRAOs were confirmed, and ischemic stroke, TIA, and amaurosis fugax events were tallied within 15 days before and after CRAO.
RESULTS
Three hundred patients with CRAO were included in the study cohort. The median age at the time of CRAO was 72 years (range, 19-100 years), and 158 (53%) were male patients. Overall, 16 patients (5.3%) had symptomatic ischemic stroke around the time of CRAO, with 7 strokes (2.3%) occurring 15 days before CRAO, 4 (1.3%) occurring simultaneously with CRAO, and 5 (1.7%) occurring after CRAO. Transient ischemic attack and amaurosis fugax were seen in 5 (1.7%) and 26 (8.7%) patients, respectively. It was found that 7% (9/128) of patients with embolic CRAO had a stroke around the time of CRAO as compared with 1.3% (2/149) of patients with an unknown cause of CRAO.
CONCLUSION
Symptomatic stroke, TIA, or amaurosis fugax is common around the time of CRAO. Therefore, CRAOs require urgent embolic work-ups.
Topics: Adult; Aged; Aged, 80 and over; Computed Tomography Angiography; Female; Follow-Up Studies; Humans; Incidence; Magnetic Resonance Imaging; Male; Middle Aged; Retinal Artery Occlusion; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Time Factors; Ultrasonography; United States; Young Adult
PubMed: 30711121
DOI: 10.1016/j.mayocp.2018.10.018 -
Radiology Oct 2022Background MRI and fluorine 18-labeled sodium fluoride (F-NaF) PET can be used to identify features of plaque instability, rupture, and disease activity, but large... (Observational Study)
Observational Study
Background MRI and fluorine 18-labeled sodium fluoride (F-NaF) PET can be used to identify features of plaque instability, rupture, and disease activity, but large studies have not been performed. Purpose To evaluate the association between F-NaF activity and culprit carotid plaque in acute neurovascular syndrome. Materials and Methods In this prospective observational cohort study (October 2017 to January 2020), participants underwent F-NaF PET/MRI. An experienced clinician determined the culprit carotid artery based on symptoms and record review. F-NaF uptake was quantified using standardized uptake values and tissue-to-background ratios. Statistical significance was assessed with the Welch, χ, Wilcoxon, or Fisher test. Multivariable models were used to evaluate the relationship between the imaging markers and the culprit versus nonculprit vessel. Results A total of 110 participants were evaluated (mean age, 68 years ± 10 [SD]; 70 men and 40 women). Of the 110, 34 (32%) had prior cerebrovascular disease, and 26 (24%) presented with amaurosis fugax, 54 (49%) with transient ischemic attack, and 30 (27%) with stroke. Compared with nonculprit carotids, culprit carotids had greater stenoses (≥50% stenosis: 30% vs 15% [ = .02]; ≥70% stenosis: 25% vs 4.5% [ < .001]) and had increased prevalence of MRI-derived adverse plaque features, including intraplaque hemorrhage (42% vs 23%; = .004), necrotic core (36% vs 18%; = .004), thrombus (7.3% vs 0%; = .01), ulceration (18% vs 3.6%; = .001), and higher F-NaF uptake (maximum tissue-to-background ratio, 1.38 [IQR, 1.12-1.82] vs 1.26 [IQR, 0.99-1.66], respectively; = .04). Higher F-NaF uptake was positively associated with necrosis, intraplaque hemorrhage, ulceration, and calcification and inversely associated with fibrosis ( = .04 to < .001). In multivariable analysis, carotid stenosis at or over 70% (odds ratio, 5.72 [95% CI: 2.2, 18]) and MRI-derived adverse plaque characteristics (odds ratio, 2.16 [95% CI: 1.2, 3.9]) were both associated with the culprit versus nonculprit carotid vessel. Conclusion Fluorine 18-labeled sodium fluoride PET/MRI characteristics were associated with the culprit carotid vessel in study participants with acute neurovascular syndrome. Clinical trial registration no. NCT03215550 and NCT03215563 © RSNA, 2022
Topics: Aged; Carotid Arteries; Constriction, Pathologic; Female; Fluorine; Fluorine Radioisotopes; Humans; Magnetic Resonance Imaging; Male; Plaque, Atherosclerotic; Positron-Emission Tomography; Prospective Studies; Sodium Fluoride
PubMed: 35670715
DOI: 10.1148/radiol.212283 -
Thrombosis Research Jan 2016The possible significance of thrombophilia in ischemic stroke remains controversial. We aimed to study inherited and acquired thrombophilias as risk factors for ischemic...
INTRODUCTION
The possible significance of thrombophilia in ischemic stroke remains controversial. We aimed to study inherited and acquired thrombophilias as risk factors for ischemic stroke, transient ischemic attack (TIA) and amaurosis fugax in young patients.
MATERIALS AND METHODS
We included patients aged 18 to 50 years with ischemic stroke, TIA or amaurosis fugax referred to thrombophilia investigation at Aarhus University Hospital, Denmark from 1 January 2004 to 31 December 2012 (N=685). Clinical information was obtained from the Danish Stroke Registry and medical records. Thrombophilia investigation results were obtained from the laboratory information system. Absolute thrombophilia prevalences and associated odds ratios (OR) with 95% confidence intervals (95% CI) were reported for ischemic stroke (N=377) and TIA or amaurosis fugax (N=308). Thrombophilia prevalences for the general population were obtained from published data.
RESULTS
No strong associations were found between thrombophilia and ischemic stroke, but patients with persistent presence of lupus anticoagulant (3%) had an OR at 2.66 (95% CI 0.84-9.15) for ischemic stroke. A significantly higher risk of TIA/amaurosis fugax was found for factor V Leiden heterozygote (12%) (OR: 1.99 (95% CI 1.14-3.28)). No other inherited or acquired thrombophilia was associated with ischemic stroke, TIA or amaurosis fugax.
CONCLUSIONS
In young patients, thrombophilia did not infer an increased risk of ischemic stroke. Only factor V Leiden heterozygote patients had an increased risk of TIA/amaurosis fugax, and persistent presence of lupus anticoagulant was likely associated with ischemic stroke. We suggest the testing restricted to investigation of persistent presence of lupus anticoagulant.
Topics: Adolescent; Adult; Age Distribution; Biomarkers; Causality; Comorbidity; Denmark; Factor V; Female; Humans; Lupus Coagulation Inhibitor; Male; Middle Aged; Prevalence; Risk Factors; Stroke; Thrombophilia; Young Adult
PubMed: 26585761
DOI: 10.1016/j.thromres.2015.11.006 -
Cureus Mar 2022Carotid stump syndrome (CSS) is a rare cause of recurrent ipsilateral cerebrovascular events that typically manifests as transient ischemic attacks or amaurosis fugax....
Carotid stump syndrome (CSS) is a rare cause of recurrent ipsilateral cerebrovascular events that typically manifests as transient ischemic attacks or amaurosis fugax. The cause of these recurrent symptoms is thought to be microembolization from an occluded internal carotid artery that reaches intracranial circulation through anastomoses. We undertook a systematic literature review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the PubMed, Web of Science, and Embase databases of the endovascular treatment options for CSS. Nine papers met the inclusion criteria and provided patient data on 12 patients, and one case illustration is presented. Treatment was with common carotid artery-external carotid artery stent graft without concomitant coil embolization in nine patients and with coil embolization without stenting, the breakthrough of the stump with a wire and subsequent internal carotid artery stent placement, and stent-assisted coil embolization in one patient each. During a median follow-up of six months, all patients were on dual antiplatelet therapy except one on undefined "systemic anticoagulation." Twelve patients had no symptoms after treatment, one had transient expressive aphasia but no further symptoms after being placed on anticoagulation, and none had intraprocedural complications or had to undergo retreatment. Our review indicates that endovascular treatment of CSS is associated with low intraprocedural risk and is effective at treating recurrent symptoms.
PubMed: 35371850
DOI: 10.7759/cureus.22746 -
Journal of the Neurological Sciences May 2022Diagnosing giant cell arteritis (GCA) can be challenging due to the variable clinical presentation and lack of systemic symptoms in approximately 20% of cases, which are...
BACKGROUND
Diagnosing giant cell arteritis (GCA) can be challenging due to the variable clinical presentation and lack of systemic symptoms in approximately 20% of cases, which are termed occult GCA. GCA affects the ocular circulation in more than half of cases and can cause irreversible bilateral blindness if not rapidly recognized and treated. We compared clinical and laboratory findings of patients with occult and systemic temporal artery biopsy (TAB)-positive GCA with ocular manifestations.
METHODS
Retrospective chart review of patients with TAB-positive GCA with ocular manifestations seen at a tertiary neuro-ophthalmology practice between 2015 and 2020.
RESULTS
GCA was occult in 14.3% (6/42) and systemic in 85.7% (36/42) of patients. Occult GCA affected older patients (average age 84.6 ± 5.3 vs 75.9 ± 8.2). There was no significant difference in ESR or CRP levels between two cohorts. In patients with occult GCA, 83.3% (5/6) presented with AION, and 16.7% (1/6) with isolated cranial nerve six palsy (CN6P). In the systemic GCA cohort, 47.2% (17) presented with AION, 5.6% (2) with CRAO, 2.8% (1) with PION, 2.8% (1) with isolated CWS, 2.8% (1) had both CRAO and AION, 2.8% (1) isolated cranial nerve 4 palsy (CN4P), 2.8% (1) isolated CN6P, 22.2% (8) had history of amaurosis fugax but normal examination, and 11.1% (4) had visual symptoms but a normal exam. Three of the above patients with AION also had CN4P. Of patients diagnosed with AION, presenting visual acuity in the affected eye(s) was significantly worse in patients with occult GCA. Involvement of multiple ocular circulations was seen in six patients in the systemic group but none in the occult group.
CONCLUSION
Occult GCA occurs more commonly in older patients who most of the time present with AION. Levels of inflammatory markers were similar in the occult and systemic groups. Though ocular ischemic manifestations were similar in both cohorts, in systemic GCA involvement of multiple ocular circulations is likely more common GCA should always be considered in older patients who present with signs of retinal and/or optic nerve head ischemia (AION and/or CWS) and new onset of CNPs, especially in patients where more than one ocular arterial circulation is involved.
Topics: Aged; Aged, 80 and over; Canada; Giant Cell Arteritis; Humans; Ischemia; Optic Neuropathy, Ischemic; Paralysis; Retrospective Studies; Temporal Arteries
PubMed: 35276478
DOI: 10.1016/j.jns.2022.120222 -
Postgraduate Medical Journal Apr 2021Neuro-ophthalmological emergency disorders typically present with symptoms of visual loss, diplopia, ocular motility impairment or anisocoria. The ocular manifestations... (Review)
Review
Neuro-ophthalmological emergency disorders typically present with symptoms of visual loss, diplopia, ocular motility impairment or anisocoria. The ocular manifestations of these disorders are sometimes indicative of a more serious global neurology disease rather than an isolated ocular disease. The aim of this review is to highlight four important neuro-ophthalmological emergency disorders that must not be missed by an ophthalmologist. These include acute painful Horner's syndrome, painful cranial nerve III palsy, giant cell arteritis and transient ischaemic attack with amaurosis fugax. The delayed diagnosis of these clinical entities puts the patient at risk of blindness or death. Therefore, prompt diagnosis and management of these conditions are essential. This can be acquired from understanding the main signs and symptoms of the disease presentation together with a high index of suspicion while working at a busy eye emergency department.
Topics: Blindness; Emergency Service, Hospital; Giant Cell Arteritis; Horner Syndrome; Humans; Ischemic Attack, Transient; Oculomotor Nerve Diseases
PubMed: 32788313
DOI: 10.1136/postgradmedj-2020-138163 -
Clinical Ophthalmology (Auckland, N.Z.) 2016To describe the time course of management of patients with amaurosis fugax and analyze differences in management by different specialties.
PURPOSE
To describe the time course of management of patients with amaurosis fugax and analyze differences in management by different specialties.
METHODS
Patients diagnosed with amaurosis fugax and subjected to carotid ultrasound in 2004-2010 at the Sahlgrenska University Hospital, Gothenburg, Sweden (n=302) were included in this retrospective cohort study, and data were collected from medical records.
RESULTS
The prevalence of significant carotid stenosis was 18.9%, and 14.2% were subjected to carotid endarterectomy. A trend of longer delay for surgery was noted for patients first consulting a general practitioner (=0.069) as compared to hospital-based specialties. For 46.3% of the patients, an ophthalmologist was their first medical contact. No significant difference in time interval to endarterectomy was seen between ophthalmologists and neurologists/internists. Only 31.8% of the patients with significant carotid stenosis had carotid endarterectomy within 2 weeks from the debut of symptoms, and this proportion was smaller for patients residing outside the Gothenburg city area (=0.038).
CONCLUSION
Initially consulting an ophthalmologist does not delay the time to ultrasound or carotid endarterectomy. The overall time from symptoms to surgery is longer than recommended for a majority of the patients, especially for patients from rural areas and for patients initially consulting a general practitioner.
PubMed: 27895459
DOI: 10.2147/OPTH.S115660 -
The International Journal of... Apr 2015The aim of this study was to find out if local brain circulatory problems may influence visual-evoked potentials (VEP).
PURPOSE
The aim of this study was to find out if local brain circulatory problems may influence visual-evoked potentials (VEP).
PATIENTS AND METHODS
Thirty-eight patients were divided into the following groups: (I) those with hemianopsia or quadrantanopsia and hemiparesis after brain stroke; (II) those with hemianopsia or quadrantanopsia without paresis after brain stroke; and (III) those with amaurosis fugax. The control group consisted of 38 patients. The VEP pattern (PVEP) and flash VEP (FVEP) were examined monocularly using two electrodes placed at O1 and O2. Latency and amplitude of the N75, P100 and N2, P2 waves were measured. The Newman-Keuls test was used for statistical analysis.
RESULTS
In PVEP, no differences between the groups were observed. In FVEP, the mean P2 latency was significantly longer in group I than in group III, and the P2 amplitude was significantly lower in all examined groups when compared with the control group. PVEP and FVEP revealed differences in P latency over 3 ms between brain hemispheres and differences in P amplitude over 30% in all examined groups. In the control group, there were no differences in latency between brain hemispheres and only a small difference in amplitude.
CONCLUSION
Local brain circulatory problems that may lead to brain ischemia cause differences in VEP amplitude and latency between brain hemispheres. Changes in VEPs observed in patients with amaurosis fugax may be considered the result of recurrent brain ischemia.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrovascular Circulation; Cerebrovascular Disorders; Electroencephalography; Evoked Potentials, Visual; Female; Humans; Male; Middle Aged; Perceptual Disorders; Photic Stimulation; Reaction Time; Visual Fields; Young Adult
PubMed: 24901952
DOI: 10.3109/00207454.2014.931386 -
Journal of Vascular Surgery Apr 2022The current risk assessment for patients with carotid atherosclerosis relies primarily on measuring the degree of stenosis. More reliable risk stratification could...
OBJECTIVE
The current risk assessment for patients with carotid atherosclerosis relies primarily on measuring the degree of stenosis. More reliable risk stratification could improve patient selection for targeted treatment. We have developed and validated a model to predict for major adverse neurologic events (MANE; stroke, transient ischemic attack, amaurosis fugax) that incorporates a combination of plaque morphology, patient demographics, and patient clinical information.
METHODS
We enrolled 221 patients with asymptomatic carotid stenosis of any severity who had undergone computed tomography angiography at baseline and ≥6 months later. The images were analyzed for carotid plaque morphology (plaque geometry and tissue composition). The data were partitioned into training and validation cohorts. Of the 221 patients, 190 had complete records available and were included in the present analysis. The training cohort was used to develop the best model for predicting MANE, incorporating the patient and plaque features. First, single-variable correlation and unsupervised clustering were performed. Next, several multivariable models were implemented for the response variable of MANE. The best model was selected by optimizing the area under the receiver operating characteristic curve (AUC) and Cohen's kappa statistic. The model was validated using the sequestered data to demonstrate generalizability.
RESULTS
A total of 62 patients had experienced a MANE during follow-up. Unsupervised clustering of the patient and plaque features identified single-variable predictors of MANE. Multivariable predictive modeling showed that a combination of the plaque features at baseline (matrix, intraplaque hemorrhage [IPH], wall thickness, plaque burden) with the clinical features (age, body mass index, lipid levels) best predicted for MANE (AUC, 0.79), In contrast, the percent diameter stenosis performed the worst (AUC, 0.55). The strongest single variable for discriminating between patients with and without MANE was IPH, and the most predictive model was produced when IPH was considered with wall remodeling. The selected model also performed well for the validation dataset (AUC, 0.64) and maintained superiority compared with percent diameter stenosis (AUC, 0.49).
CONCLUSIONS
A composite of plaque geometry, plaque tissue composition, patient demographics, and clinical information predicted for MANE better than did the traditionally used degree of stenosis alone for those with carotid atherosclerosis. Implementing this predictive model in the clinical setting could help identify patients at high risk of MANE.
Topics: Biomarkers; Carotid Arteries; Carotid Artery Diseases; Carotid Stenosis; Computed Tomography Angiography; Constriction, Pathologic; Hemorrhage; Humans; Magnetic Resonance Imaging; Plaque, Atherosclerotic
PubMed: 34793923
DOI: 10.1016/j.jvs.2021.10.056