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Clinical Ophthalmology (Auckland, N.Z.) 2012The purpose of this research was to assess associations of thrombophilia with central retinal vein occlusion (CRVO), central retinal artery occlusion (CRAO), and...
PURPOSE
The purpose of this research was to assess associations of thrombophilia with central retinal vein occlusion (CRVO), central retinal artery occlusion (CRAO), and amaurosis fugax (AF); to evaluate outcomes of normalizing high homocysteine; and to study CRVO, CRAO, and AF developing in estrogens/estrogen agonists in women subsequently shown to have thrombophilia.
METHODS
Measures of thrombophilia-hypofibrinolysis were obtained in 132 CRVO cases, 15 CRAO cases, and 17 AF cases. Cases were compared to 105 healthy control subjects who did not differ by race or sex and were free of any ophthalmologic disorders. All cardiovascular disease (CVD) risk factors were compared to healthy general populations.
MAIN OUTCOME MEASURES
The main outcome measure of this study was thrombophilia.
RESULTS
CRVO cases were more likely than controls to have high homocysteine (odds ratio [OR] 8.64, 95% confidence intervals [CI]: 1.96-38), high anticardiolipin immunoglobulin M (IgM; OR 6.26, 95% CI: 1.4-28.2), and high Factor VIII (OR 2.47, 95% CI: 1.31-7.9). CRAO-AF cases were more likely than controls to have high homocysteine (OR 14, 95% CI: 2.7-71.6) or the lupus anticoagulant (OR 4.1, 95% CI: 1.3-13.2). In four of 77 women with CRVO (two found to have high homocysteine, two with inherited high Factor XI), CRVO occurred after starting estrogen-progestins, estrogen-testosterone, or estrogen agonists. In one of eight women with CRAO found to have high anticardiolipin antibody IgG, CRAO occurred after starting conjugated estrogens, and AF occurred after starting conjugated estrogens in one of eleven women with AF (inherited protein S deficiency). Therapy for medians of 21 months (CRVO) and 6 months (CRAO-AF) was 5 mg folic acid, 100 mg B6, and 2000 mcg/day B12 normalized homocysteine in 13 of 16 (81%) CRVO cases and all five CRAO-AF cases with pretreatment hyperhomocysteinemia. The CRVO cases had an excess of hypertension; CRAO-AF cases had an excess of type 2 diabetes and hypertension.
CONCLUSION
Treatable thrombophilia, hyperhomocysteinemia in particular, is more common in RVO cases than in normal controls. RVO occurs after estrogens or estrogen agonists were administered in women subsequently shown to have thrombophilia.
PubMed: 22969282
DOI: 10.2147/OPTH.S34627 -
JRSM Cardiovascular Disease Jan 2014Stroke remains an exceedingly incident and prevalent public health burden across the globe, with an estimated 16 million new strokes per annum and prevalence over 60... (Review)
Review
Stroke remains an exceedingly incident and prevalent public health burden across the globe, with an estimated 16 million new strokes per annum and prevalence over 60 million, and extracranial internal carotid artery atherosclerotic disease is an important risk factor for stroke. Randomized trials of surgical treatment were conducted (North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial) and demonstrated efficacy of carotid endarterectomy for secondary prevention of stroke in patients with cerebrovascular events (e.g. ipsilateral stroke, transient ischemic attack, and/or amaurosis fugax) attributable to a diseased artery with 50-99% stenosis. Therapeutic clarity, however, proved elusive with asymptomatic carotid artery disease. Asymptomatic Carotid Atherosclerosis Study (ACAS), Asymptomatic Carotid Surgery Trial, and Veterans Affairs Cooperative Study (VACS) suggested only modest benefit from surgical intervention for primary stroke prevention and the best medical therapy at the time of these trials is not comparable to modern medical therapy. ACT-1, Asymptomatic Carotid Surgery Trial-2, Stent-Protected Angioplasty in asymptomatic Carotid artery stenosis versus Endarterectomy Trial-2, European Carotid Surgery Trial-2, Carotid Revascularization Endarterectomy Versus Stenting Trial-2 are trials that are recent, ongoing, or in development that include diverse populations across Europe and North America, complementary trial designs, and a collaborative spirit that should provide clinicians with evidence that informs best clinical practice for asymptomatic carotid artery disease.
PubMed: 25247072
DOI: 10.1177/2048004014529419 -
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 -
Brazilian Journal of Cardiovascular... Oct 2022There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated...
INTRODUCTION
There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated the surgical results in this high-risk group in our clinic for a decade.
METHODS
Between 2005 and 2015, 196 patients were treated for combined carotid and coronary artery disease. A total of 50 patients were operated on with the staged method, 40 of which had carotid endarterectomy (CEA) priority, and 10 had coronary artery bypass grafting (CABG) priority. CABG and CEA were simultaneously performed in 82 patients; and in 64 asymptomatic patients with unilateral carotid artery lesions and stenosis over 70%, only CABG was done (64 patients). Results were evaluated by uni-/multivariate analyses for perioperative, early, and late postoperative data.
RESULTS
In the staged group, interval between the operations was 2.82±0.74 months. Perioperative and early postoperative (30 days) parameters did not differ between groups (P-value < 0.05). Postoperative follow-up time was averaged 94.9±38.3 months. Postoperative events were examined in three groups as (A) deaths (all cause), (B) cardiovascular events (non-fatal myocardial infarction, recurrent angina, congestive heart failure, palpitation), and (C) fatal neurological events (amaurosis fugax, transient ischemic attack, and stroke). When group C events were excluded, event-free actuarial survival rates were similar in all three methods (P=0.740). Actuarial survival rate was significantly different when all events were included (P=0.027). Neurological events increased markedly between months 34 and 66 (P=0.004).
CONCLUSION
Perioperative and early postoperative event-free survival rates were similar in all three methods. By the beginning of the 34th month, the only CABG group has been negatively separated due to neurological events. In the choice of methodology, "most threatened organ priority'' was considered as clinical parameter.
Topics: Humans; Carotid Stenosis; Retrospective Studies; Treatment Outcome; Postoperative Complications; Coronary Artery Disease; Stroke; Carotid Artery Diseases
PubMed: 35244376
DOI: 10.21470/1678-9741-2021-0127 -
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 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 -
Journal of Family Medicine and Primary... Dec 2020A 57-year-old female presented with headache, miosis, and ptosis diagnosed as Horner syndrome (HS). After delaying the recommended diagnostic imaging, she experienced...
A 57-year-old female presented with headache, miosis, and ptosis diagnosed as Horner syndrome (HS). After delaying the recommended diagnostic imaging, she experienced transient, unilateral visual impairment in bright light. The patient was subsequently determined to have a spontaneous internal carotid artery dissection (ICAD) and secondary retinal ischemia with minimal cardiovascular risk factors and no history of preceding trauma. She wore dark glasses, received gabapentin for pain control, and was anticoagulated for a total of 4 months at which time the ICAD resolved despite a residual blepharoptosis and anisocoria.
PubMed: 33681076
DOI: 10.4103/jfmpc.jfmpc_1444_20 -
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 -
Progress in Retinal and Eye Research Sep 2011The initial section deals with basic sciences; among the various topics briefly discussed are the anatomical features of ophthalmic, central retinal and cilioretinal...
The initial section deals with basic sciences; among the various topics briefly discussed are the anatomical features of ophthalmic, central retinal and cilioretinal arteries which may play a role in acute retinal arterial ischemic disorders. Crucial information required in the management of central retinal artery occlusion (CRAO) is the length of time the retina can survive following that. An experimental study shows that CRAO for 97min produces no detectable permanent retinal damage but there is a progressive ischemic damage thereafter, and by 4h the retina has suffered irreversible damage. In the clinical section, I discuss at length various controversies on acute retinal arterial ischemic disorders. Classification of acute retinal arterial ischemic disorders: These are of 4 types: CRAO, branch retinal artery occlusion (BRAO), cotton wool spots and amaurosis fugax. Both CRAO and BRAO further comprise multiple clinical entities. Contrary to the universal belief, pathogenetically, clinically and for management, CRAO is not one clinical entity but 4 distinct clinical entities - non-arteritic CRAO, non-arteritic CRAO with cilioretinal artery sparing, arteritic CRAO associated with giant cell arteritis (GCA) and transient non-arteritic CRAO. Similarly, BRAO comprises permanent BRAO, transient BRAO and cilioretinal artery occlusion (CLRAO), and the latter further consists of 3 distinct clinical entities - non-arteritic CLRAO alone, non-arteritic CLRAO associated with central retinal vein occlusion and arteritic CLRAO associated with GCA. Understanding these classifications is essential to comprehend fully various aspects of these disorders. Central retinal artery occlusion: The pathogeneses, clinical features and management of the various types of CRAO are discussed in detail. Contrary to the prevalent belief, spontaneous improvement in both visual acuity and visual fields does occur, mainly during the first 7 days. The incidence of spontaneous visual acuity improvement during the first 7 days differs significantly (p<0.001) among the 4 types of CRAO; among them, in eyes with initial visual acuity of counting finger or worse, visual acuity improved, remained stable or deteriorated in non-arteritic CRAO in 22%, 66% and 12% respectively; in non-arteritic CRAO with cilioretinal artery sparing in 67%, 33% and none respectively; and in transient non-arteritic CRAO in 82%, 18% and none respectively. Arteritic CRAO shows no change. Recent studies have shown that administration of local intra-arterial thrombolytic agent not only has no beneficial effect but also can be harmful. Prevalent multiple misconceptions on CRAO are discussed. Branch retinal artery occlusion: Pathogeneses, clinical features and management of various types of BRAO are discussed at length. The natural history of visual acuity outcome shows a final visual acuity of 20/40 or better in 89% of permanent BRAO cases, 100% of transient BRAO and 100% of non-arteritic CLRAO alone. Cotton wools spots: These are common, non-specific acute focal retinal ischemic lesions, seen in many retinopathies. Their pathogenesis and clinical features are discussed in detail. Amaurosis fugax: Its pathogenesis, clinical features and management are described.
Topics: Animals; Ciliary Arteries; Humans; Retina; Retinal Artery Occlusion; Visual Acuity; Visual Fields
PubMed: 21620994
DOI: 10.1016/j.preteyeres.2011.05.001 -
Internal Medicine (Tokyo, Japan) Feb 2000It has been emphasized that amaurosis fugax (AmF) is caused by thromboembolism due to atheromatous lesions of the extracranial carotid artery (EC-CA) in Caucasian... (Comparative Study)
Comparative Study
OBJECTIVE
It has been emphasized that amaurosis fugax (AmF) is caused by thromboembolism due to atheromatous lesions of the extracranial carotid artery (EC-CA) in Caucasian populations. However, there have been few studies of AmF in Japan. We analyzed the clinical and pathophysiologic features of AmF in 43 Japanese AmF patients.
SUBJECTS AND METHODS
Forty-three patients presented with AmF from a group of 2,056 Japanese patients with acute ischemic stroke. We investigated angiographic and transcranial Doppler findings, precipitating factors, medical treatment and prognosis, to elucidate the pathogenetic mechanism of AmF.
RESULTS
Angiographic findings revealed an intracranial lesion in 22 patients (51%), extracranial lesion in 16 (37%), and no abnormality in 5 (12%). Blood flow in the ophthalmic artery (OA) examined by the transcranial Doppler ultrasonography (TCD) showed normal antegrade flow in 24 patients and reversed flow in 7. Precipitating factors for AmF were seen in 7 out of 43 patients. Regarding the pathogenesis of AmF, the micro-thromboembolism originated from the internal carotid artery (ICA) in 25 patients, the thromboembolism was via the external carotid artery (ECA) in 7, the hemodynamic retinal vascular insufficiency in 6 patients showed various atheromatous changes in the intracranial carotid artery (IC-CA) or EC-CA, and the cause was unknown in 5.
CONCLUSION
In this series of patients, AmF was mainly caused by thromboembolism from IC-CA atheromatous lesions. Micro-thromboemboli from the ECA or hemodynamic retinal vascular insufficiency, although less frequent, should also be considered as possible etiologies for AmF.
Topics: Adolescent; Adult; Aged; Amaurosis Fugax; Blood Flow Velocity; Brain Ischemia; Carotid Artery Thrombosis; Cerebral Angiography; Cerebrovascular Circulation; Female; Humans; Incidence; Japan; Male; Middle Aged; Ophthalmic Artery; Retrospective Studies; Ultrasonography, Doppler, Transcranial
PubMed: 10732827
DOI: 10.2169/internalmedicine.39.118