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Seminars in Arthritis and Rheumatism Oct 2022To investigate the risk of ocular manifestations leading to hospital contacts among patients with giant cell arteritis (GCA).
OBJECTIVES
To investigate the risk of ocular manifestations leading to hospital contacts among patients with giant cell arteritis (GCA).
METHODS
A Danish, nationwide, register-based cohort study including 14,574 GCA patients diagnosed 1996-2018 and 145,740 general population referents, matched on sex and date of birth. Cumulative incidence proportions (CIPs) and relative risks (RRs) of ocular manifestations with 95% confidence intervals (CIs) were calculated using a pseudo-observation approach.
RESULTS
A total of 1026/14,574 (7.0%) GCA patients were registered with ocular manifestations within ±1 year of the diagnosis; 392/1026 (38%) being before and 634/1026 (62%) after the GCA diagnosis, and 744/1026 (73%) were registered within ±1 month of the diagnosis. The diagnoses were 336/1026 (33%) retinal vascular occlusions, 300/1026 (29%) disorders of the optic nerve, 177/1026 (17%) visual impairment, 90/1026 (9%) diplopia, and 123/1026 (12%) amaurosis fugax. The CIP for ocular manifestations among GCA patients after 3, 6, and 12 months following the diagnosis were 4.0% (95% CI: 3.6-4.3), 4.2% (95% CI: 3.9-4.6), and 4.6% (95% CI: 4.2-4.9). The 1-year RR of ocular manifestations among GCA patients was 28.0 (95% CI: 24.0-32.7), with age above 70 years, male sex, and a positive temporal artery biopsy being risk factors. Treatment with low-dose aspirin was not associated with a reduced 1-year RR of incident ocular manifestations.
CONCLUSIONS
In GCA, most cases of ocular manifestations leading to hospital contacts occur close to the time of diagnosis, with over one-third of cases occurring before the diagnosis, emphasizing the need for early recognition and treatment.
Topics: Aged; Biopsy; Cohort Studies; Giant Cell Arteritis; Hospitals; Humans; Incidence; Male; Retrospective Studies
PubMed: 35878473
DOI: 10.1016/j.semarthrit.2022.152071 -
BMC Cardiovascular Disorders Jul 2022X-ray fluoroscopy has been the primary cardiac imaging modality in permanent pacemaker implantation (PPI) operations, but it inevitably results in radiation exposure for...
BACKGROUND
X-ray fluoroscopy has been the primary cardiac imaging modality in permanent pacemaker implantation (PPI) operations, but it inevitably results in radiation exposure for both operators and patients. Fluoroscopy is considered a contraindication, especially in certain circumstances, such as gestation, during which the fetus is most sensitive to radiation exposure. Therefore, measures to avoid radiation exposure are necessary, and a more safe and feasible approach is needed for this procedure. Since the EnSite NavX mapping system (ENMS) can create the required geometric contours of those relevant cardiac structures and chambers, it can be used as an alternative to X-ray fluoroscopy in PPI. In addition, because the displacement of atrial leads is a common complication of PPI, lead displacement may occur more readily without fluoroscopic guidance. Therefore, reliable measures are required to prevent leads from displacement.
CASE INTRODUCTION
A 41-year-old woman at the 15th week of gestation was referred to our department with recurrent episodes of syncope and amaurosis fugax for 2 years. Holter monitoring showed sinus rhythm, Mobitz Type II atrioventricular block and high-grade atrioventricular block with ventricular arrest up to 4945 ms. A dual-chamber PPI was performed successfully for the patient under the guidance of the ENMS instead of fluoroscopy. Displacement of atrial lead was effectively avoided by bending the top of atrial lead before implantation and making it a U-shape during operation, which left space for possible subsequent external pulling stress.
CONCLUSIONS
For PPI, ENMS is a feasible and reliable alternative to traditional X-ray fluoroscopy, especially when performing operations on pregnant patients. By bending the top of the active-fixation atrial lead into a U-shape during operation, the displacement of atrial lead may be avoided.
Topics: Adult; Atrioventricular Block; Female; Fluoroscopy; Follow-Up Studies; Humans; Pacemaker, Artificial; Pregnancy; Pregnant Women
PubMed: 35864443
DOI: 10.1186/s12872-022-02764-w -
Cureus Jun 2022There are many causes of amaurosis fugax, including polycythemia. Polycythemia is associated with elevated hematocrit levels and hyperviscosity, which can lead to ocular...
There are many causes of amaurosis fugax, including polycythemia. Polycythemia is associated with elevated hematocrit levels and hyperviscosity, which can lead to ocular manifestations. We report a polycythemia patient with amaurosis fugax, who had resolution of ocular symptoms following venesection. A 29-year-old gentleman presented with a six-month history of episodic bilateral transient loss of vision (amaurosis fugax), followed by slow recovery back to normal after 15-20 minutes. The symptoms worsened with fatigue. He also had an unsteady gait for the preceding one year. Ocular examination was unremarkable. His visual acuity was 20/20 OU. Neurological examination revealed gait ataxia and dysdiadochokinesia. Computed tomography (CT) angiogram showed an old cerebellar infarct. Blood investigations showed persistent elevated hemoglobin and hematocrit with positive JAK-2 V617F mutation. Infective and connective tissue workups were all negative. A diagnosis of polycythemia was made by the haematology team. In addition to oral aspirin given by the neurology team, he underwent venesection with improvement in ocular symptoms following each episode of venesection. The frequency of amaurosis fugax reduced from 2-3 episodes a week to once a month, then resolved completely after five venesections. Systemically, his cerebellar symptoms also resolved and there were no neurological deficits. Polycythemia is a rare disease that can cause amaurosis fugax and thrombotic events in young patients. Better knowledge and accurate diagnosis are important, as early treatment may improve the symptoms and long-term morbidity.
PubMed: 35812629
DOI: 10.7759/cureus.25752 -
Journal of Vascular Surgery Nov 2022Shunt placement during carotid endarterectomy (CEA) has often been advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. In the...
OBJECTIVE
Shunt placement during carotid endarterectomy (CEA) has often been advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. In the present study, we assessed the effect of shunt placement during CEA on postoperative stroke risk in symptomatic patients.
METHODS
We queried the American College of Surgeons National Surgical Quality Improvement Program database (2016-2019) for CEA cases with complete CEA procedure-targeted data available. Symptomatic patients were identified as those with a preoperative diagnosis of stroke on presentation (DS), transient ischemic attack, amaurosis fugax, or temporary monocular blindness. The DS patients were further analyzed according to the severity of their stroke using the modified Rankin scale scores. To better assess the effect of shunt placement on the stroke rate, we compared cases of CEA with the patch angioplasty technique stratified by the use of an intraoperative shunt. Patients who had undergone carotid eversion or primary closure were excluded. The baseline demographics and perioperative outcomes were compared using the χ and Mann-Whitney U tests. Multivariate analysis was performed to identify the independent risk factors for postoperative stroke and cranial nerve injury.
RESULTS
We identified 4652 cases of CEA with patch angioplasty in symptomatic patients, including 1889 with (40.6%) and 2763 without (59.4%) shunt placement. The distribution of age, race, and sex was similar for both procedures. Compared with patients without a shunt, those with a shunt had significantly higher rates of emergency surgery (9.1% vs 7.0%; P = .010), nonelective surgery (40.3% vs 37.2%; P = .035), general anesthesia (97.0% vs 86.3%; P < .001), and bleeding disorders (27.2% vs 22.7%; P < .001). The 30-day incidence of postoperative stroke was similar between the patients with (3.2%) and without (2.6%) shunt placement (P = .219). Additionally, a subgroup analysis failed to show any benefit from shunt placement on the incidence of postoperative stroke, regardless of the preoperative symptoms or neurologic disability. In contrast, shunt placement was associated with an increased rate of cranial nerve injury (4.1% vs 2.4%; P = .001). Multivariate analysis revealed that nonelective surgery (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.36-2.91; P < .001) and DS (vs transient ischemic attack, amaurosis fugax, or temporary monocular blindness; OR, 1.64; 95% CI, 1.12-2.41; P = .012) were predictive of 30-day postoperative stroke. After adjusting for confounders, shunt placement had no effect on stroke risk at 30 days but remained an independent risk factor for cranial nerve injury (adjusted OR, 1.87; 95% CI, 1.32-2.64; P < .001).
CONCLUSIONS
For symptomatic patients undergoing CEA with patch angioplasty, shunt placement was associated with an increased risk of cranial nerve injury without a reduction in postoperative stroke risk.
Topics: Humans; Endarterectomy, Carotid; Ischemic Attack, Transient; Amaurosis Fugax; Treatment Outcome; Time Factors; Carotid Stenosis; Stroke; Risk Factors; Cranial Nerve Injuries; Retrospective Studies; Risk Assessment
PubMed: 35810956
DOI: 10.1016/j.jvs.2022.06.096 -
Acute and Critical Care Jul 2022Visual complications represent common deficits following surgical or endovascular repair of paraclinoid aneurysms. Different etiologies should be investigated to prevent...
Visual complications represent common deficits following surgical or endovascular repair of paraclinoid aneurysms. Different etiologies should be investigated to prevent devastating consequences. Herein we present a point-of-care evaluation to investigate sudden visual loss after coiling of paraclinoid aneurysms. A 20-year-old male was admitted for a sudden headache. Head computed tomography showed a subarachnoid hemorrhage and subsequent angiography revealed a 9-mm left supraclinoid aneurysm of the internal carotid artery treated with endovascular coil embolization. Thirty minutes after intensive care unit admission, the patient reported a left amaurosis. To exclude secondary etiologies, an immediate evaluation with point-of-care devices (color-doppler and B-mode ultrasound and automated pupillometry) was performed. Sonographic evaluations were negative for ischemic/thrombotic events and neurologic pupil index within physiological ranges provide evidence of third cranial nerve responsiveness. The symptomatology resolved progressively over 120 minutes with low-dose steroid therapy, 30° head-of-bed elevation, and blood pressure management. Visual deficits can occur after endovascular procedure and should be investigated. Suspected visual loss is a neurological emergency that deserves a prompt evaluation. Ultrasound and automated pupillometry have proved to be an effective, rapid, reliable, and non-invasive combination for a clinical decision-making strategy in the management of post-procedural acute visual deficits.
PubMed: 35791652
DOI: 10.4266/acc.2022.00045 -
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 -
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 -
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 -
Case Reports in Oncology 2022Oxaliplatin, a third-generation platinum-based agent, is a constitutive part of systemic treatment for colorectal cancer in adjuvant and metastatic settings. Ocular...
Oxaliplatin, a third-generation platinum-based agent, is a constitutive part of systemic treatment for colorectal cancer in adjuvant and metastatic settings. Ocular toxicity is an extremely rare adverse effect of Oxaliplatin. Ocular toxicities have been documented in the form of (a) common (≥1/100, <1/10) which include the conjunctivitis, unexpected lacrimation, blurry vision, blepharoptosis, and (b) uncommon (≥1/10,000, <1/1,000) which compromise the tunnel vision, idiosyncratic color perception, transient bilateral visual loss, and rarest phenomenon of Amaurosis fugax. Amaurosis fugax implies to any cause of transient, painless, unilateral visual loss; with the possible underlying mechanism of thrombo-embolic carotid plaque, hypoperfusion, or vasospasm of retinal vessels, due to hyperviscosity, and atherosclerotic vascular disease. To date, only a few case reports of Oxaliplatin-induced Amaurosis fugax have been published. We here-in report 3 cases who experienced Amaurosis fugax while receiving Oxaliplatin in our one of health board-based four hospitals.
PubMed: 35350803
DOI: 10.1159/000521842 -
Neurology India 2022Mechanical stimulation may lead to internal carotid artery (ICA) dissection and aneurysm.
BACKGROUND
Mechanical stimulation may lead to internal carotid artery (ICA) dissection and aneurysm.
CASE DESCRIPTION
We encountered a rare case of ICA dissection and aneurysm with prolonged styloid process (SP) fracture. A 37-year-old sales worker presented with right-sided amaurosis fugax. After admission to a nearby optical clinic, he was admitted to our hospital. Computed tomography angiography (CTA) and digital subtraction angiography showed dissection and apparent aneurysmal change in the right cervical portion of the ICA. CTA also showed elongated SPs, so we diagnosed Eagle's syndrome, and fracture of the right-side process. After 2 weeks of antiplatelet therapy, the aneurysm enlarged and dissection remained, so we treated the patient with coil embolization and stenting.
CONCLUSION
We encountered a rare case of ICA dissection and aneurysm with Eagle's syndrome. Endovascular treatment was performed because the SP was fractured.
Topics: Adult; Angiography, Digital Subtraction; Carotid Arteries; Carotid Artery, Internal; Carotid Artery, Internal, Dissection; Humans; Male; Ossification, Heterotopic; Temporal Bone
PubMed: 35263916
DOI: 10.4103/0028-3886.338648