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Thrombosis and Haemostasis Feb 2022
Topics: Ad26COVS1; Amaurosis Fugax; Anticoagulants; Carotid Artery Thrombosis; Humans; Ischemic Stroke; Male; Middle Aged; Recurrence; Syndrome; Thrombocytopenia; Thrombosis; Vaccination
PubMed: 34670287
DOI: 10.1055/a-1674-0341 -
Acta Ophthalmologica Jun 2022We describe hypoperfusion-related and embolic ocular signs of carotid stenosis (CS) before and six months after carotid endarterectomy (CEA) in a CS population.
PURPOSE
We describe hypoperfusion-related and embolic ocular signs of carotid stenosis (CS) before and six months after carotid endarterectomy (CEA) in a CS population.
METHODS
We enrolled prospectively 70 CEA patients (81% male, mean age 69) and 41 non-medicated control subjects (76%, 68), from March 2015 to December 2018, assessing intraocular pressure (IOP), best-corrected visual acuity (BCVA) in logMAR units and performing a bio-microscopy examination.
RESULTS
Main index symptoms included amaurosis fugax (Afx) (29, 41%) and hemispheric TIA (17, 24%), and 17 (24%) were asymptomatic. Of the 70, 17 patients (24%, 95% CI 16-36) showed ocular signs of CS. Of four embolic (Hollenhorst plaques) findings, one small macular plaque disappeared postoperatively. Four had hypoperfusion, that is ocular ischaemic syndrome (OIS), requiring panretinal photocoagulation: one for multiple mid-peripheral haemorrhages, two for iris neovascularization and one for neovascular glaucoma (NVG); only the NVG proved irreversible. Nine (de novo in three) showed mild OIS, that is only few mid-peripheral haemorrhages, ranging pre- /postoperatively in ipsilateral eyes from one to eleven (median two)/ one to two (median one), and in contralateral eyes from three to nine (median five)/ one to six (median three). Pre- and postoperative median BCVA was 0 or better, and mean IOP was normal, except in the NVG patient. Temporary visual impairment from 0 to 0.3 occurred in one eye soon after CEA due to ocular hyperperfusion causing macular oedema.
CONCLUSIONS
Ocular signs of CS are common in CEA patients, ranging from few mid-peripheral haemorrhages to irreversible NVG. Clinicians should be aware of these signs in detecting CS.
Topics: Aged; Carotid Stenosis; Choroid; Endarterectomy, Carotid; Female; Glaucoma, Neovascular; Humans; Male; Prospective Studies
PubMed: 34633762
DOI: 10.1111/aos.15019 -
Surgical Neurology International 2021An elongated styloid process is known to cause ischemic stroke. Previous reports claim that internal carotid artery (ICA) dissection due to the elongated styloid process...
BACKGROUND
An elongated styloid process is known to cause ischemic stroke. Previous reports claim that internal carotid artery (ICA) dissection due to the elongated styloid process has good outcomes when treated conservatively; however, long-term follow-up has not been attempted and recurrence in the later period has not been reported so far. We report a case of recurrence of symptoms over a decade after the initial onset.
CASE DESCRIPTION
A 59-year-old man experienced a transient ischemic attack (TIA) 10 years ago. Six years ago, he experienced hemispheric TIA, and magnetic resonance angiography revealed a diminished signal of the left ICA; however, no further examination was performed. Four years ago, he experienced another transient amaurosis attack and was treated with antiplatelet therapy because no embolic source was detected using ultrasonography examination, and he was diagnosed with idiopathic ICA dissection. Recently, he experienced a third amaurosis fugax attack. Digital subtraction angiography and cone-beam computed tomography demonstrated left cervical ICA dissection due to elongated styloid process. He underwent surgical resection of the left styloid process and cervical stent placement. He had no ischemic attacks postoperatively.
CONCLUSION
The elongated styloid process may cause recurrent ischemic attacks over a decade due to ICA dissection.
PubMed: 34621588
DOI: 10.25259/SNI_536_2021 -
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 -
Ophthalmology Feb 2022To determine the risk of stroke, transient ischemic attack (TIA), and transient monocular vision loss (TMVL) before and after a central retinal artery occlusion (CRAO).
PURPOSE
To determine the risk of stroke, transient ischemic attack (TIA), and transient monocular vision loss (TMVL) before and after a central retinal artery occlusion (CRAO).
DESIGN
Population-based, retrospective case series.
PARTICIPANTS
Patients diagnosed with a CRAO in Olmsted County, Minnesota, from 1976 to 2016.
METHODS
Patients living in Olmsted County with a diagnosis code of CRAO from 1976 to 2016 were reviewed. New CRAOs were confirmed, and stroke, TIA, and TMVL events in the 15 days before and after CRAO were recorded.
MAIN OUTCOME MEASURES
Incidence of stroke, TIA, and TMVL events in the 15 days before and after CRAO.
RESULTS
Eighty-nine patients with a CRAO were identified, providing an annual incidence of 2.58/100 000 (95% confidence interval [CI], 2.04-3.11). Median age at the time of CRAO was 76 years (range, 46-100 years); 56.2% were male, and 89.9% of the cohort was White. In the 15 days before and after CRAO, there were 2 ischemic strokes (2.2%), 1 hemorrhagic stroke (1.1%), 2 TIAs (2.2%), and 9 TMVL events (10.1%). Starting in 1999, 15 of 45 patients underwent magnetic resonance imaging within 2 months of CRAO. One patient (6.7%) had evidence of asymptomatic diffusion restriction, and 9 patients (60%) had a remote infarct.
CONCLUSIONS
This population-based study demonstrated that the risk of symptomatic ischemic stroke is 2.2% in the 15 days before and after a CRAO, which is slightly lower than most studies from tertiary centers. These data should be considered as practice recommendations are developed regarding the urgency of neurovascular workup in patients with acute CRAO.
Topics: Aged; Aged, 80 and over; Amaurosis Fugax; Female; Humans; Incidence; Ischemic Attack, Transient; Magnetic Resonance Imaging; Male; Middle Aged; Minnesota; Retinal Artery Occlusion; Retrospective Studies; Risk Factors; Stroke; Visual Acuity
PubMed: 34303745
DOI: 10.1016/j.ophtha.2021.07.017 -
Case Reports in Oncology 2021Oxaliplatin-associated amaurosis fugax has not been reported, and its clinical course and treatment remain largely unclear. A 70-year-old man with advanced gastric...
Oxaliplatin-associated amaurosis fugax has not been reported, and its clinical course and treatment remain largely unclear. A 70-year-old man with advanced gastric cancer was treated with the SOX regimen. After cycle 1 of oxaliplatin infusion, the patient realized that his right eye had visual field impairment, which he described as darkening of the right half of his visual field and loss of vision lasting about 1 min and occurring about 7 times a day. The daily frequency of this occurrence gradually decreased, and his visual field impairment improved in 1 week. However, as the same symptoms recurred from cycle 2 to cycle 5 of treatment, oxaliplatin was discontinued from cycle 6 and switched to S-1 monotherapy. Subsequently, the patient's amaurosis fugax improved. To our knowledge, this is the first report describing clinical course and treatment of oxaliplatin-associated amaurosis fugax.
PubMed: 34248547
DOI: 10.1159/000516271 -
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 -
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 -
European Journal of Medical Research Jun 2021Central retinal artery occlusion (CRAO) is an emergent ophthalmic disease which is commonly caused by atherosclerosis, thromboembolism, and arteriospasm. Here, we report... (Review)
Review
Monocular central retinal artery occlusion caused by bilateral internal carotid artery hypoplasia complicated with patent foramen ovale: a case report and review of literature.
BACKGROUND
Central retinal artery occlusion (CRAO) is an emergent ophthalmic disease which is commonly caused by atherosclerosis, thromboembolism, and arteriospasm. Here, we report a case of CRAO which is caused by extreme rare bilateral internal carotid artery (ICA) hypoplasia complicated with patent foramen ovale (PFO). The cardiogenic emboli blocked central retinal artery through unclosed foramen ovale and specific blood flow pathway.
CASE PRESENTATION
This report describes a case of a 46-year-old woman sudden onset with amaurosis fugax for about 20 min and persistent visual impairment of left eye. Fundus fluorescein angiography shows the arm-retinal circulation time of left eye is 25 s, indicating that the occlusion occurs in the pathway from aortic arch to ophthalmic artery. The MRA and CTA examinations reveal the bilateral ICA hypoplasia and variation of Wills circle. Furthermore, transesophageal echocardiography (TEE) confirms the PFO and cardiogenic embolic event.
CONCLUSIONS
This work presents a CRAO case caused by rare congenital hypoplasia of ICA complicated with PFO, reminding us every single cause of vascular disease should be investigated carefully and the TOAST typing of cerebrovascular disease can be of great reference to the ocular vascular disease.
Topics: Carotid Artery Diseases; Carotid Artery, Internal; Computed Tomography Angiography; Echocardiography, Transesophageal; Female; Fluorescein Angiography; Follow-Up Studies; Foramen Ovale, Patent; Fundus Oculi; Humans; Magnetic Resonance Angiography; Middle Aged; Retinal Artery Occlusion; Retinal Vessels
PubMed: 34120645
DOI: 10.1186/s40001-021-00530-w -
EJVES Vascular Forum 2021A carotid endarterectomy (CEA) has certain risks, of which peri-operative cardiovascular risk is one. Peri-operative neurological monitoring can be done with...
INTRODUCTION
A carotid endarterectomy (CEA) has certain risks, of which peri-operative cardiovascular risk is one. Peri-operative neurological monitoring can be done with electroencephalography (EEG) and transcranial Doppler (TCD). No previous reports have been published demonstrating the actual changes in cerebral and cardiac activity during a peri-operative asystole.
REPORT
The case of a 70 year old man with a symptomatic (bilateral) carotid stenosis is described. The patient complained of amaurosis fugax in both eyes. Duplex ultrasound showed a stenosis of >70% in both carotid arteries. The most severe symptoms were on the right side, so a staged approach was chosen, starting with a right sided eversion CEA (eCEA). Peri-operatively, the patient experienced an asystolic cardiac arrest after external carotid artery revascularisation, requiring brief cardiopulmonary resuscitation, which was recorded on the EEG. Post-operatively, the patient recovered fully, with no post-operative neurological or cardiac sequelae. The (symptomatic) contralateral stenosis was treated conservatively with best medical therapy (BMT; dual antiplatelets and statin). The patient is currently in good clinical condition, 1.5 years later.
CONCLUSION
This case shows the unique EEG recording of a cardiological event during eCEA. The cause of asystole was most likely a vasovagal syncope as a result of the surgical procedure by iatrogenic damage to the carotid sinus fibres, causing impairment of the baroreflex and chemoreflex mechanisms, which is greater during eCEA. The unilateral eCEA and contralateral BMT in this symptomatic (bilateral) stenosis seemed appropriate when cardiological risk was increased but follow up ruled out any cardiological cause.
PubMed: 34041506
DOI: 10.1016/j.ejvsvf.2021.04.001