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International Journal of Retina and... Jun 2022The present case aims to describe a previously healthy man who presented multiple attacks of transient monocular visual loss after Pfizer-BioNTech COVID-19 vaccination...
BACKGROUND
The present case aims to describe a previously healthy man who presented multiple attacks of transient monocular visual loss after Pfizer-BioNTech COVID-19 vaccination and to discuss the possible mechanisms related to occurrence of this condition.
CASE PRESENTATION
We report a case of multiple attacks of transient monocular visual loss in a previously healthy middle-aged man two weeks after Pfizer-BioNTech COVID-19 vaccination. TVL attacks were described as sudden and painless complete visual loss, lasting about one minute, followed by a full recovery. He presented several non-simultaneous attacks in both eyes, 16 in the right eye, and 2 in the left eye on the same day, fifteen days after receiving the second dose of the Pfizer-BioNTech COVID-19 vaccine. The brain's magnetic resonance angiography, echocardiogram, and doppler ultrasound imaging of the carotid and vertebral arteries were non-revealing. The complete blood exam revealed a slightly elevated C-reactive protein test. We assessed fundus examination during the transient visual loss attack and revealed diffuse vascular narrowing for both arterial and venous branches, notably in the emergence of the optic disc in right eye. In addition, the circumpapillary optical coherence tomography angiography (OCTA) vessel density map was reduced. Oral verapamil hydrochloride 60 mg twice daily was initiated, and the attacks of transient visual loss improved after two days.
CONCLUSIONS
To date, and the best of our knowledge, this is the first case report of multiple transient monocular visual loss attacks due to retinal vasospasm in a previously healthy middle-aged man documented by fundus retinography and OCTA. We discuss in this article the possible association of retinal vasospasm and Pfizer-BioNTech COVID-19 vaccination, probably related to vaccine-induced inflammation.
PubMed: 35725633
DOI: 10.1186/s40942-022-00393-1 -
Frontiers in Neurology 2021In patients with carotid stenosis, to investigate the relationship between carotid intraplaque hemorrhage (IPH) and total burden of cerebral small vessel disease (CSVD)...
In patients with carotid stenosis, to investigate the relationship between carotid intraplaque hemorrhage (IPH) and total burden of cerebral small vessel disease (CSVD) and preliminarily explore whether the total CSVD burden as an imaging marker can distinguish the severity of clinical symptoms. A total of 108 patients (the mean age was 66 ± 7 years, and 85.2% were male) with unilateral carotid stenosis ≥50% underwent brain MRI and high-resolution MRI for carotid plaque characterization. The total burden of CSVD was calculated by accumulating one point according to the presence or severity of each of the four MRI markers: white matter hyperintensities, lacunes, perivascular spaces, and cerebral microbleeds. Recent clinical symptoms including transient ischemic attack, amaurosis fugax, and ischemic stroke were recorded. The association between intraplaque hemorrhage (IPH) and total CSVD burden was examined adjusted for other risk factors. The symmetry of CSVD burdens between the ipsilateral and contralateral hemispheres of IPH was tested. Imaging features (CSVD score, IPH, degree of stenosis, and completeness of the circle of Willis) were correlated with clinical symptoms by Kruskal-Wallis H test, Chi-square test, and Fisher's exact test. Multivariable logistic regression analysis showed that IPH (OR = 2.98, 95% CI [1.39, 6.40], = 0.005) was independently associated with a higher CSVD score. The presence of unilateral IPH was associated with the inter-hemispheric CSVD score difference ( = 0.004). Patients with stroke had a higher ipsilateral CSVD score than asymptomatic patients ( = 0.004) and those with transient ischemic attack/amaurosis fugax ( = 0.008). The statistical difference was marginally significant between symptoms and IPH ( = 0.057). No statistical difference was found between the symptoms and degree of stenosis and the completeness of the circle of Willis ( > 0.05). Carotid IPH is associated with an elevated total burden of CSVD in patients with carotid stenosis. Compared with the degree of stenosis, primary collaterals, and IPH, the total CSVD score might be a more effective imaging marker linked with clinical symptoms.
PubMed: 34721263
DOI: 10.3389/fneur.2021.731237 -
Cureus May 2021Tolosa-Hunt syndrome (THS) is a fascinating condition that is ipso facto a cavernous sinus syndome. As such it is associated with inflammation of the cavernous sinus...
Tolosa-Hunt syndrome (THS) is a fascinating condition that is ipso facto a cavernous sinus syndome. As such it is associated with inflammation of the cavernous sinus walls and contents with spread to contiguous structures such as the orbital apex and superior orbital fissure. Therefore it does not come as a surprise that there is overlap with the condition of orbital pseudotumor. Furthermore, the typical presentation of THS involves variable affliction of the contents of the cavernous sinus with ocular and facial pain, ophthalmoplegia, facial numbness and Horner syndrome. To our knowledge, we present one of the only reported cases of recurrent amaurosis fugax and transient visual obscurations secondary to THS. Despite being an odd-ball presentation, these manifestations make intuitive sense as we demonstrate luminal narrowing of the right carotid siphon in the setting of cavernous wall enhancement, peri-arteritis of the carotid siphon being well-documented pathologically in the literature. The basis for the transient visual obscurations is more speculative but worthy of further study.
PubMed: 34221749
DOI: 10.7759/cureus.15281 -
International Angiology : a Journal of... Aug 2021The risk of ischemic stroke in patients with chronic total occlusion (CTO) of the internal carotid artery (ICA) on best medical treatment has been estimated to be 5.5%...
BACKGROUND
The risk of ischemic stroke in patients with chronic total occlusion (CTO) of the internal carotid artery (ICA) on best medical treatment has been estimated to be 5.5% per year. The purpose of this study was to assess early and mid-term outcome of patients who underwent an attempt at transfemoral carotid artery stenting (CAS) for CTO of the ICA.
METHODS
Clinical data of symptomatic patients who underwent attempt at CAS for CTO of the ICA between January 1, 2010 and July 1, 2020 were retrospectively reviewed. Clinical success, perioperative and mid-term stroke and death rates were recorded. Descriptive statistics were used.
RESULTS
There were 27 patients, 14 females, 13 males, with a mean age of 66.8 years, range: 57 to 79. All patients had symptoms within 6 months prior to the procedure. 16 had ipsilateral stroke at a mean of 2.8 months, ranges: 1.5-4 months, two had transient ischemic attack (TIA), at 1 week and at 6 months, one had amaurosis fugax at one week, two had chronic ocular ischemia and six had chronic cerebral hypoperfusion. Technical success was 52% (14/27). One patient developed a minor reversible stroke (1/27, 3.7%) there was no early death, for an overall 30-day stroke and death rate of 3.7% (1/27). Two patients had perioperative TIAs. Among 14 patients with successful CAS (group A) one had minor, reversible ipsilateral stroke during a follow-up of 29 months (range: 4-112), two had contralateral stroke. There was no death. One patient developed asymptomatic stent occlusion, three had asymptomatic in-stent restenosis >50%, two had reinterventions. Among patients with unsuccessful attempt at CAS (group B), 31% (4/13) had stroke at 4, 10, 14 and 22 months, respectively. One stroke patient died at 10 months.
CONCLUSIONS
Transfemoral CAS of symptomatic patients with CTO of the ICA was feasible in half of the patients, with no mortality or major stroke, for an overall early stroke/death rate of 3.7%. Since one third of the patients with unsuccessful stenting developed stroke during follow-up, further studies to investigate the safety, efficacy and durability of CAS for CTO of the ICA are needed.
Topics: Aged; Carotid Artery, Internal; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Male; Middle Aged; Retrospective Studies; Stents; Stroke; Treatment Outcome
PubMed: 34528772
DOI: 10.23736/S0392-9590.21.04662-9 -
Cureus Aug 2023In this case report, we highlight a case of a 24-year-old primigravida who suffered a sudden and painless loss of vision and headache in the immediate postpartum period....
In this case report, we highlight a case of a 24-year-old primigravida who suffered a sudden and painless loss of vision and headache in the immediate postpartum period. Vision loss was transient and remarkable. Her brain magnetic resonance imaging revealed vasogenic edema in parieto-occipital white matter, suggestive of posterior reversible encephalopathy syndrome. Posterior reversible encephalopathy syndrome is a clinical-radiological entity, having hemodynamic catastrophe also known as reversible posterior cerebral edema syndrome. It tends to occur during pregnancy complicated by eclampsia. Hypertension and a hypercoagulable tendency tend to engulf the entire homeostasis into its deadly clutches sending the autoregulation into a frizzy. It presents with a gamut of red flags like headache, seizures, encephalopathy, amaurosis fugax, cortical visual disturbances, and even blindness. Clinical improvement was seen with supportive treatment in this patient. Thus, timely diagnosis and intervention help reverse the dire consequences.
PubMed: 37727199
DOI: 10.7759/cureus.43703 -
European Journal of Vascular and... Apr 2020This study investigates the prognostic significance of pre-operative symptom status and type of symptom in outcomes after carotid endarterectomy (CEA). (Meta-Analysis)
Meta-Analysis
OBJECTIVE
This study investigates the prognostic significance of pre-operative symptom status and type of symptom in outcomes after carotid endarterectomy (CEA).
METHODS
This review was conducted and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) to identify studies reporting peri-operative outcomes of CEA in symptomatic and asymptomatic patients. The last search was conducted in August 2019 and a methodological assessment was performed using the Newcastle Ottawa Scale. A meta-analysis of outcome data using the odds ratio (OR) as the summary statistic was conducted, and the precision of the effect was reported as 95% confidence interval (CI). Fixed effect or random effects models were used to calculate the pooled estimates.
RESULTS
Eighteen studies reporting a total of 91 895 patients were included in the meta-analysis. Asymptomatic patients had a lower peri-operative risk of stroke (OR 0.5, 95% CI 0.45-0.54; p < .001) and death (OR 0.66, 95% CI 0.57-0.77; p < .001) than symptomatic patients, but the risk of myocardial infarction was not significantly different (OR 0.98, 95% CI 0.84-1.15; p = .82). Those suffering a pre-procedural stroke had an increased peri-operative risk of stroke and death vs. patients suffering a pre-procedural transient ischaemic attack or amaurosis fugax.
CONCLUSION
Patients undergoing CEA after a stroke have worse peri-operative outcomes in terms of stroke and death. Further research needs to be performed to ascertain the value of this finding in risk stratification systems and to investigate potential aetiological associations between pre-operative symptom status and peri-operative risk following a CEA.
Topics: Amaurosis Fugax; Carotid Stenosis; Endarterectomy, Carotid; Humans; Ischemic Attack, Transient; Myocardial Infarction; Postoperative Complications; Preoperative Period; Prognosis; Risk Assessment; Stroke; Symptom Assessment; Time Factors; Treatment Outcome
PubMed: 32081531
DOI: 10.1016/j.ejvs.2020.01.022 -
Stroke Nov 2020Research suggests that women and men may present with different transient ischemic attack (TIA) and stroke symptoms. We aimed to explore symptoms and features associated...
BACKGROUND AND PURPOSE
Research suggests that women and men may present with different transient ischemic attack (TIA) and stroke symptoms. We aimed to explore symptoms and features associated with a definite TIA/stroke diagnosis and whether those associations differed by sex.
METHODS
We completed a retrospective cohort study of patients referred to The Ottawa Hospital Stroke Prevention Clinic in 2015. Exploratory multinomial logistic regression was used to evaluate candidate variables associated with diagnosis and patient sex. Backwards elimination of the interaction terms with a significance level for staying in the model of 0.25 was used to arrive at a more parsimonious model.
RESULTS
Based on 1770 complete patient records, sex-specific differences were noted in TIA/stroke diagnosis based on features such as duration of event, suddenness of symptom onset, unilateral sensory loss, and pain.
CONCLUSIONS
This preliminary work identified sex-specific differences in the final diagnosis of TIA/stroke based on common presenting symptoms/features. More research is needed to understand if there are biases or sex-based differences in TIA/stroke manifestations and diagnosis.
Topics: Aged; Aged, 80 and over; Amaurosis Fugax; Aphasia; Carotid Stenosis; Cohort Studies; Dysarthria; Female; Hemianopsia; Humans; Ischemic Attack, Transient; Male; Middle Aged; Pain; Paresis; Retrospective Studies; Sex Factors; Smoking; Somatosensory Disorders; Time Factors
PubMed: 32993462
DOI: 10.1161/STROKEAHA.120.031510 -
Annals of Vascular Surgery Nov 2020There is no current consensus on the best criteria for selective shunting during carotid endarterectomy (CEA). The choice of continuous neurologic assessment during...
BACKGROUND
There is no current consensus on the best criteria for selective shunting during carotid endarterectomy (CEA). The choice of continuous neurologic assessment during awake CEA, intraoperative electroencephalogram, or carotid stump pressure monitoring as the basis for shunt placement is primarily dependent on surgeon preference. Our goal is to define a safe stump pressure threshold as a guide for selective shunting.
METHODS
The study is a single-surgeon retrospective review of consecutive patients who underwent CEA under general anesthesia with selective shunting based on intraoperative stump pressure measurements from 2001 to 2019. Demographic and periprocedural variables were analyzed using standard statistical techniques.
RESULTS
Among 399 patients, 68% were male with a mean age of 70. One-third of the patients were symptomatic, with amaurosis fugax in 12%, transient ischemic attack in 7%, and stroke in 16%. In total, 60 (15%) patients underwent shunting: 34 for a confirmed preoperative acute ischemic stroke, 22 for a stump pressure <30 mm Hg, and 4 for other indications. Overall 30-day death, ischemic ipsilateral stroke, myocardial infarction, and cranial nerve palsy rates were 0.5%, 0.8%, 1.8%, and 1.0%, respectively. No strokes occurred due to hypoperfusion, and all stroke symptoms resolved prior to discharge with a mean length of stay of 1.6 days.
CONCLUSIONS
This is one of the largest contemporary series of CEA using a 30 mm Hg threshold for selective shunting that demonstrated exceedingly low 30-day death and stroke events. Intraoperative carotid stump pressure measurements are a useful guide for selective shunting and reduction in perioperative stroke complications after CEA.
Topics: Aged; Aged, 80 and over; Arterial Pressure; Brain Ischemia; Carotid Arteries; Carotid Stenosis; Constriction; Endarterectomy, Carotid; Female; Humans; Male; Middle Aged; Retrospective Studies; Risk Factors; Stroke; Time Factors; Treatment Outcome
PubMed: 32554199
DOI: 10.1016/j.avsg.2020.06.002 -
Journal of Vascular Surgery Nov 2019We sought to analyze the association between last neurologic event and the risk of stroke or death among patients treated with carotid endarterectomy (CEA) or carotid...
Last neurologic event is associated with risk of in-hospital stroke or death after carotid endarterectomy or carotid artery stenting: Secondary data analysis of the German statutory quality assurance database.
OBJECTIVE
We sought to analyze the association between last neurologic event and the risk of stroke or death among patients treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS) under routine conditions in Germany.
METHODS
Secondary data analysis was performed based on the German statutory quality assurance database for carotid procedures. A total of 144,347 patients treated by CEA and 14,794 patients treated by CAS were included in the analysis. Primary outcome was any in-hospital stroke or death. To analyze the association between the last neurologic event and outcome, multilevel multivariable regression analysis was performed.
RESULTS
In patients treated by CEA, raw risk for any in-hospital stroke or death was 2.0% (2923/144,347), with a risk of 1.4% in asymptomatic and 3.0% in symptomatic patients. In patients treated by CAS, raw risk for any in-hospital stroke or death was 3.6% (538/14,794), with a risk of 1.7% in asymptomatic and 6.1% in symptomatic patients. Regression analysis revealed that increasing severity of last neurologic event was significantly associated with an increasing risk of any in-hospital stroke or death in patients treated by both CEA and CAS (P < .004). However, the risk of any stroke or death did not significantly differ between asymptomatic patients and patients with amaurosis fugax before CEA or CAS (P = .219 for CEA, P = .124 for CAS).
CONCLUSIONS
Increasing severity of last neurologic event is associated with an increasing risk of any in-hospital stroke or death in patients treated by CEA and CAS. The risk of any stroke or death did not differ between asymptomatic patients and patients with amaurosis fugax.
Topics: Aged; Amaurosis Fugax; Asymptomatic Diseases; Carotid Stenosis; Databases, Factual; Endarterectomy, Carotid; Female; Germany; Hospital Mortality; Humans; Male; Middle Aged; Postoperative Complications; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Treatment Outcome
PubMed: 31416653
DOI: 10.1016/j.jvs.2019.02.038 -
European Journal of Vascular and... Aug 2021The risk of ipsilateral neurological recurrence (NR) was assessed in patients awaiting carotid endarterectomy (CEA) due to symptomatic carotid artery stenosis and... (Observational Study)
Observational Study
OBJECTIVE
The risk of ipsilateral neurological recurrence (NR) was assessed in patients awaiting carotid endarterectomy (CEA) due to symptomatic carotid artery stenosis and whether current national guidelines of performing CEA within 14 days are adequate in present day practice.
METHODS
This was a retrospective multicentre observational cohort study. Patients scheduled for CEA due to symptomatic carotid artery stenosis in a five year period, 1 January 2014 to 31 December 2018, from four centres were included. Data from the Danish Vascular Registry (www.karbase.dk), operative managing systems, and electronic medical records were reviewed.
RESULTS
In total, 1 125 patients scheduled for CEA were included and 1 095 (97%) underwent the planned surgery. During a median delay from index event to CEA of 11 days (interquartile range 8-16 days), 40 patients (3.6%; 95% confidence interval [CI] 2.5%-5%) experienced a NR. One third were minor strokes (n = 12, 30%); half were transient ischaemic attacks (TIA) (n = 22, 55%); and amaurosis fugax accounted for 15% (n = 6). Twenty-six (2%) CEA procedures was cancelled, of which one was due to a disabling recurrent ischaemic event (aphasia). There were no deaths or major strokes in the waiting time for CEA. Best medical treatment (BMT) with platelet inhibitory or anticoagulation drugs and a statin was initiated in nearly all patients (98%) at first assessment. The overall 30 day risk of a post-operative major event (death or stroke) was (Kaplan-Meier [KM] estimate) 2.7% (95% CI 1.8-3.8), and not significantly correlated with the timing of surgery. Most (69%) occurred within the first three days. One, two, and three year mortality rate for CEA patients was (KM estimate) 4.8%, 7.8%, and 11.5% respectively.
CONCLUSION
In symptomatic carotid artery stenosis patients awaiting CEA, very few NRs occurred within 14 days. Institution of immediate BMT in specialised TIA/stroke units followed by early, but not necessarily urgent, CEA is a reasonable course of action in patients with high grade symptomatic carotid artery stenosis.
Topics: Aged; Aged, 80 and over; Amaurosis Fugax; Anticoagulants; Carotid Stenosis; Denmark; Drug Therapy, Combination; Endarterectomy, Carotid; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Ischemic Stroke; Kaplan-Meier Estimate; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Recurrence; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Survival Rate; Time-to-Treatment
PubMed: 34127375
DOI: 10.1016/j.ejvs.2021.04.016