Amaurosis fugax and ocular infarction in adolescents and young adults

Transient Monocular Visual Loss (Amaurosis Fugax): How Does Age Impact Diagnosis?

Transient monocular visual loss (TMVL), also known as transient monocular blindness or amaurosis fugax ("fleeting blindness"), is a temporary loss of vision often due to ischemia to the retina. While acute TMVL should be considered an emergency that further requires exhaustive investigation, there are some cases in which TMVL arises secondary to benign causes. Age has a major impact in the diagnosis of ischemia and although the differential diagnosis of TMVL can be broad, timely and appropriate history, examination, diagnostic testing, and treatment can be vision- or life-saving. We review the causes of TMVL and the impact of age on the differential diagnoses and management.

Risk factors for ischemic cerebral stroke in patients with acute amaurosis fugax

OBJECTIVE

The National Stroke Association and the American Heart Association consider retinal ischemia, as in the case of amaurosis fugax (AF), to be a stroke event. The purpose of this study was to evaluate the risk factors for ischemic cerebral stroke in patients hospitalized for acute AF.

METHODS

The National Inpatient Sample Database from 2002 to 2014 was used to identify patients 21 years of age and older with a primary admission diagnosis of AF with the ICD-9 code 362.34. Comorbidity measures and in-hospital events were extracted using relevant ICD-9 codes. Statistical analyses were performed using IBM SPSS 25 and R package.

RESULTS

A weighted total of 12,142 patients was identified. The most common comorbidities in this cohort with AF included hypertension, dyslipidemia, tobacco use, coronary artery disease (CAD), and diabetes mellitus. Multivariable regression analysis showed comorbidities of hypercoagulable state, systemic vasculitis, CAD, and atherosclerosis to be independent risk factors for ischemic stroke in patients with AF. In contrast, dyslipidemia was associated with a decreased risk. Asian/Pacific Islander race conferred a 5-fold increased risk compared with Whites.

CONCLUSION

Ischemic stroke and myocardial infarction were diagnosed in 0.3%-0.9% of hospitalized acute AF cases. Presence of hypercoagulable state, systemic vasculitis, CAD, and atherosclerosis each individually increased the risk of ischemic stroke by more than 3-fold; patients with these risk factors and acute AF should be closely monitored for developing acute systemic thrombotic events.

Yield of Investigations in Young Patients Presenting With Transient Monocular Vision Loss: A Prospective Study

PURPOSE

It is unclear whether transient monocular vision loss (TMVL) warrants the same thorough systemic evaluation for potential embolic sources in young adults as it does in older adults. The objective of the present study was to evaluate the yield of investigations in patients under 45 years of age presenting with TMVL.

DESIGN

Prospective cohort study.

METHODS

Young adult patients with TMVL presenting to a university-affiliated neuro-ophthalmology clinic were included. All included patients were referred for neuroimaging (computed tomography or magnetic resonance angiography of entire carotid tree and magnetic resonance imaging of the brain) and cardiac investigations (transesophageal echocardiography and 2 weeks of Holter monitoring).

RESULTS

A total of 20 participants with TMVL were included in the study. The mean age was 33.1 ± 8.2 years, and 16 of the 20 participants were women. The most common finding on past medical history was migraines, in 5 of 20 cases (25%), and 25% of patients had headaches during their visual loss. Of 17 participants who completed neuroimaging, 1 had fibromuscular dysplasia (this patient also experienced headaches during their symptoms). Two of 13 patients who completed echocardiography had patent foramen ovale. Overall, 3 of 20 participants (15%, 95% CI 3%-38%) had abnormal findings associated with their TMVL. Aspirin treatment was initiated in 2 of 3 patients following investigations.

CONCLUSION

In our cohort of young patients presenting with TMVL, 15% of patients had abnormal findings on further investigations. We recommend that young patients presenting with TMVL be referred for neuroimaging and cardiac workup so that appropriate treatments can be initiated to prevent future complications. Headaches during vision loss may not always indicate a benign cause, and retinal migraine should be a diagnosis of exclusion.

Retinal migraine, a contentious clinical entity

" Retinal migraine (ophthalmic migraine, ocular migraine, anterior visual pathway migraine) is a rarely encountered medical condition, but with an interesting and complex clinical presentation. The goal of this article is to compile the literature on retinal migraine, detailing nomenclature, pathophysiology, differential diagnosis, and medical investigations including newer imaging modalities, like optical coherence tomography (OCT). We will approach topics of great concern such as risk factors, complications, treatment, and management of this condition. Retinal migraine is mainly a diagnosis of exclusion and it must be isolated from transient monocular vision loss (TMVL) developed from other causes, for instance, papilledema, giant cell arteritis, carotid artery disease (amaurosis fugax), intermittent angle closure glaucoma, and others. Its treatment is similar to migraine treatment; topiramate, amitriptyline, and nortriptyline are some of the pharmacological drugs successfully used."

Transient Visual Loss in Young Females with Crowded Optic Discs: A Proposed Aetiology

I present four cases of transient visual loss (TVL) in young females with crowded optic discs. One patient had asymmetrical cup-to-disc ratios and only experienced TVL in the eye with the more crowded disc. I review the evidence for blood flow autoregulatory dysfunction within crowded optic discs in combination with reduced ocular perfusion pressure to propose a possible aetiology for both unilateral and bilateral TVL in young females with crowded optic discs.

Requirement for Head Magnetic Resonance Imaging in Children Who Present to the Emergency Department With Acute Nontraumatic Visual Disturbance

OBJECTIVES

This study aimed to investigate the clinical features and head magnetic resonance imaging (MRI) findings in children who presented to the emergency department with acute nontraumatic visual disturbance and to study related clinical factors for discovering positive lesions on head MRI.

METHODS

We performed a retrospective study of 1-month to 15-year-old children who underwent head MRI as an evaluation for acute nontraumatic visual disturbance as a chief complaint in our pediatric emergency department between March 2010 and March 2015. The symptoms of visual disturbance were blurred vision, diplopia, loss of vision, and visual hallucination. Head MRI findings were considered positive when lesions could explain the symptoms.

RESULTS

We identified 39 patients (25 with blurred vision, 9 with diplopia, 3 with loss of vision, and 2 with visual hallucination) with a mean age of 8.35 ± 4.06 years. Positive head MRI findings were identified in 13 patients (33.3%). Brain tumors were most common (53.8%), followed by optic nerve inflammations (23.1%), congenital brain lesions (15.4%), and hypertensive encephalopathy (7.7%). Compared with the negative head MRI group, the positive head MRI group showed significantly less transient visual disturbance (duration <1 hour to complete recovery) (P = 0.001), more limited eye movement (P = 0.003), and more pupillary abnormalities (P = 0.030).

CONCLUSIONS

We suggest performing urgent head MRI in children with acute nontraumatic visual disturbance if the symptoms last longer than 1 hour without complete recovery and are accompanied by limited eye movement or pupillary abnormality.

Acute retinal arterial ischemia

Acute retinal arterial ischemia, which includes transient monocular vision loss (TMVL), branch retinal artery occlusion (BRAO), central retinal artery occlusion (CRAO) and ophthalmic artery occlusion (OAO), is most commonly the consequence of an embolic phenomenon from the ipsilateral carotid artery, heart or aortic arch, leading to partial or complete occlusion of the central retinal artery (CRA) or its branches. Acute retinal arterial ischemia is the ocular equivalent of acute cerebral ischemia and is an ophthalmic and medical emergency. Patients with acute retinal arterial ischemia are at a high risk of having further vascular events, such as subsequent strokes and myocardial infarctions (MIs). Therefore, prompt diagnosis and urgent referral to appropriate specialists and centers is necessary for further work-up (such as brain magnetic resonance imaging with diffusion weighted imaging, vascular imaging, and cardiac monitoring and imaging) and potential treatment of an urgent etiology (e.g., carotid dissection or critical carotid artery stenosis). Since there are no proven, effective treatments to improve visual outcome following permanent retinal arterial ischemia (central or branch retinal artery occlusion), treatment must focus on secondary prevention measures to decrease the likelihood of subsequent ischemic events.

Transient monocular blindness: Vascular causes and differential diagnoses

Transient monocular blindness is an acute episode of ischemic origin in which one eye has profound visual loss, followed by full recovery within one hour. Transient monocular blindness most often occurs in the setting of retinal ischemia secondary to carotid embolism, but other mechanisms have been reported, including thrombosis (most often in the setting of giant cell arteritis), hemodynamic disorders (secondary to severe carotid stenosis), or vasospasm. Transient monocular blindness is considered a transient ischemic attack originating in the carotid arteries, and must be managed the same as transient ischemic attack involving the brain, in order to prevent a subsequent stroke.

Transient monocular blindness and the risk of vascular complications according to subtype: a prospective cohort study

Patients with transient monocular blindness (TMB) can present with many different symptoms, and diagnosis is usually based on the history alone. In this study, we assessed the risk of vascular complications according to different characteristics of TMB. We prospectively studied 341 consecutive patients with TMB. All patients were interviewed by a single investigator with a standardized questionnaire; reported symptoms were classified into predefined categories. We performed Cox regression analyses with adjustment for baseline vascular risk factors. During a mean follow-up of 4.0 years, the primary outcome event of vascular death, stroke, myocardial infarction, or retinal infarction occurred in 60 patients (annual incidence 4.4 %, 95 % confidence interval (CI) 3.4-5.7). An ipsilateral ischemic stroke occurred in 14 patients; an ipsilateral retinal infarct in six. Characteristics of TMB independently associated with subsequent vascular events were: involvement of only the peripheral part of the visual field (hazard ratio (HR) 6.5, 95 % CI 3.0-14.1), constricting onset of loss of vision (HR 3.5, 95 % CI 1.0-12.1), downward onset of loss of vision (HR 1.9, 95 % CI 1.0-3.5), upward resolution of loss of vision (HR 2.0, 95 % CI 1.0-4.0), and the occurrence of more than three attacks (HR 1.7, 95 % CI 1.0-2.9). We could not identify characteristics of TMB that predicted a low risk of vascular complications. In conclusion, careful recording the features of the attack in patients with TMB can provide important information about the risk of future vascular events.

More clinical observations on migraine associated with monocular visual symptoms in an Indian population

Context:

Retinal migraine (RM) is considered as one of the rare causes of transient monocular visual loss (TMVL) and has not been studied in Indian population.

Objectives:

The study aims to analyze the clinical and investigational profile of patients with RM.

Materials and Methods:

This is an observational prospective analysis of 12 cases of TMVL fulfilling the International Classification of Headache Disorders-2nd edition (ICHD-II) criteria of RM examined in Neurology and Ophthalmology Outpatient Department (OPD) of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh from July 2011 to October 2012.

Results:

Most patients presented in 3^rd and 4^th decade with equal sex distribution. Seventy-five percent had antecedent migraine without aura (MoA) and 25% had migraine with Aura (MA). Headache was ipsilateral to visual symptoms in 67% and bilateral in 33%. TMVL preceded headache onset in 58% and occurred during headache episode in 42%. Visual symptoms were predominantly negative except in one patient who had positive followed by negative symptoms. Duration of visual symptoms was variable ranging from 30 s to 45 min. None of the patient had permanent monocular vision loss. Three patients had episodes of TMVL without headache in addition to the symptom constellation defining RM. Most of the tests done to rule out alternative causes were normal. Magnetic resonance imaging (MRI) brain showed nonspecific white matter changes in one patient. Visual-evoked potential (VEP) showed prolonged P100 latencies in two cases. Patent foramen ovale was detected in one patient.

Conclusions:

RM is a definite subtype of migraine and should remain in the ICHD classification. It should be kept as one of the differential diagnosis of transient monocular vision loss. We propose existence of “acephalgic RM” which may respond to migraine prophylaxis.

Recurrent Spontaneous Paresthesia in the Upper Limb Could Be Due to Migraine: A Case Series

Transient neurologic dysfunction is a characteristic feature of migraine. About 20% of migraineurs may experience various symptoms in the absence of any headache at one time or another. Visual auras are the most common auras of migraine, and migraine is considered as the most common cause of transient vision loss in young patients. Sensory auras are the second most common migrainous auras. However, the literature is silent for isolated sensory aura as a migraine equivalent. Herein we report 14 patients with recurrent episodic paresthesia in the limbs and other body parts. All patients fulfilled the diagnostic criteria of "typical aura without headache" of ICHD-3β. All patients were subjected to various investigations to rule out secondary causes. Ten patients received antimigraine drugs and all showed a positive response to therapy. Recurrent spontaneous paresthesia is quite common in the general population and many patients remain undiagnosed. We speculate that a subset of patients might be related to migrainous sensory auras.

Redefining amaurosis fugax

Amaurosis fugax is a common term fraught with different interpretations. Disparities inunderstanding appear to be related to professional training. A new framework to facilitateinterdisciplinary communication and clinical research is presented.

Migraine and epilepsy: review of the literature

Migraine and epilepsy are disorders that are common, paroxysmal, and chronic. In many ways they are clearly different diseases, yet there are some pathophysiological overlaps, and overlaps in clinical symptomatology, particularly with regard to visual and other sensory disturbances, pain, and alterations of consciousness. Epidemiological studies have revealed that the two diseases are comorbid in a number of individuals. Both are now recognized as originating from electrical disturbances in the brain, although their wider manifestations involve the recruitment of multiple pathogenic mechanisms. An initial excess of neuronal activity in migraine leads to cortical spreading depression and aura, with the subsequent recruitment of the trigeminal nucleus leading to central sensitization and pain. In epilepsy, neuronal overactivity leads to the recruitment of larger populations of neurons firing in a rhythmic manner that constitutes an epileptic seizure. Migraine aura and headaches may act as a trigger for epileptic seizures. Epilepsy is not infrequently accompanied by preictal, ictal, and postictal headaches that often have migrainous features. Genetic links are also apparent between the two disorders, and are particularly evident in the familial hemiplegic migraine syndromes where different mutations can produce either migraine, epilepsy, or both. Also, various medications are found to be effective for both migraine and epilepsy, again pointing to a commonality and overlap between the two disorders.

Recurrent transient monocular blindness from stenotic central retinal artery

Transient monocular blindness (TMB) is caused by a temporary reduction of blood flow to the retina or optic nerve. Even though embolism from the ipsilateral carotid artery has been considered the main mechanism of TMB, the vascular pathology remains unknown in many patients. A 42-year-old man presented with recurrent transient visual loss in the left eye for 2 months. The attacks tended to develop more frequently when his head was bent down. Fluorescence angiography during an attack revealed hypoperfusion of the left central retinal artery (CRA) and cerebral angiography documented a focal isolated stenosis of the CRA at the origin. Aspirin and nimodipine reduced the attacks markedly. Stenosis of the CRA may be a cause of TMB. Intermittent vasospasm in addition to static hypoperfusion may have caused TMB in our patient with isolated CRA stenosis.

Stroke in the young: The multiethnic prospective durban stroke data bank results

AIM

To determine the clinical syndromes, etiopathogenesis, and prognostic factors in a prospectively evaluated multiethnic young stroke population.

METHODS

Only first-ever patients with a World Heath Organization definition of stroke and anatomic brain imaging were included. A hierarchy of investigative modalities divided into three tiers was applied and a range of standardized scales scored in each patient. This allowed quantification of clinical deficit, etiopathogenesis, disability, and handicap. Standardized stroke scales included the Canadian Neurological Scale (CNS), the Oxfordshire Community Stroke Project (OCSP) clinical stroke scale, and TOAST (Trial of Org 10172 in Acute Stroke Study) etiological classification. Disability was measured with the Barthel Index and handicap with the Rankin Scale; cognitive impairment was separately evaluated according to predefined criteria. A prognostication measure was made in some patients with the Cerebral Perfusion Index (CPI).

RESULTS

A total of 236 patients was evaluated of whom 64 were excluded because of no lesion consistent with stroke on brain scanning leaving 172 for analysis. There were 87 women, 85 men, with a mean age of 43.8 years (range, 15 to 49 years). Despite many different predefined symptoms, 38 patients (22%) could not be classified. Hypertension (31%) and smoking (19%) were the most commonly encountered risk factors, with more recently determined risk factors such as infection (6%) and emotional stress (5%) relatively frequent. With respect to etiology, the TOAST category "other" was the most numerous group, numbering 93 of 172 (55%) with prothrombotic states in 25 (15%), vasculitis in 21 (12%), and dissection in 12 (7%) being the most frequent causes. Proportions of the remaining categories were small vessel disease (16%), cardioembolism (13%), large vessel disease (10%), and unknown (6%). X-square analysis for an association between the clinical OCSP and TOAST classifications was not significant. Severity of stroke was generally mild as judged by the CNS and Rankin scales. A high proportion of patients had cognitive impairment (54%). A cerebral perfusion index was possible in 31 patients, most of whom had a medium prognosis.

CONCLUSION

in this hospital-based consecutive series, most young stroke patients in our region were grouped into nonatherogenic (mostly prothrombotic states, infection asssociated and dissection) and noncardiac causes with a definite or probable cause found in 94%. The wide variety of stroke symptoms recorded in this study underscores the heterogeneity of stroke presentation and caution in the emergent evaluation of patients. Cognitive impairment in the majority of stroke patients in the acute and subacute stroke period has important implications for degree of clinical deficit especially as it applies to stroke scales and treatment trials.

Patterns of non-embolic transient monocular visual field loss

The aim of this study was to systematically describe the semiology of non-embolic transient monocular visual field loss (neTMVL). We conducted a retrospective case note analysis of patients from Moorfields Eye Hospital (1995-2007). The variables analysed were age, age of onset, gender, past medical history or family history of migraine, eye affected, onset, duration and offset, perception (pattern, positive and negative symptoms), associated headache and autonomic symptoms, attack frequency, and treatment response to nifedipine. We identified 77 patients (28 male and 49 female). Mean age of onset was 37 years (range 14-77 years). The neTMVL was limited to the right eye in 36 % to the left in 47 % and occurred independently in either eye in 5 % of cases. A past medical history of migraine was present in 12 % and a family history in 8 %. Headache followed neTMVL in 14 % and was associated with autonomic features in 3 %. The neTMB was perceived as grey in 35 %, white in 21 %, black in 16 % and as phosphenes in 9 %. Most frequently neTMVL was patchy 20 %. Recovery of vision frequently resembled attack onset in reverse. In 3 patients without associated headache the loss of vision was permanent. Treatment with nifedipine was initiated in 13 patients with an attack frequency of more than one per week and reduced the attack frequency in all. In conclusion, this large series of patients with neTMVL permits classification into five types of reversible visual field loss (grey, white, black, phosphenes, patchy). Treatment response to nifidipine suggests some attacks to be caused by vasospasm.

Migraine-associated vertigo: diagnosis and treatment

Migraine-associated vertigo has become a well-recognized disease entity diagnosed based on a clinical history of recurrent vertigo attacks unexplained by other central or peripheral otologic abnormalities, which occurs in the patient with a history of migraine headaches. There is no international agreement on what spectrum of symptoms should be covered under this diagnosis, or what terminology should be used. The headaches and vestibular symptoms of migraine-associated vertigo may not be temporally associated, which often obscures the association. Diagnostic tests usually show nonspecific abnormalities that are also seen in patients with migraine who do not experience vestibular symptoms. Management generally follows the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications and medical treatment with beta blockers, calcium channel blockers, and tricyclic amines. Small case series show that acetazolamide and lamotrigine appear to be more effective for the vertigo attacks than headaches. Vestibular rehabilitation has also been shown to be helpful in several studies. In this review, the epidemiologic and clinical features of the disorder, as well as the current state of knowledge on pathophysiology, diagnostic testing, and treatment are described.

Reflux of jugular and retrobulbar venous flow in transient monocular blindness

OBJECTIVE

Transient monocular blindness (TMB) attacks may occur during straining activities that impede cerebral venous return. Disturbance of cerebral and orbital venous circulation may be involved in TMB.

METHODS

Duplex ultrasonography and Doppler-flow measurement of jugular and retrobulbar veins were performed in 134 consecutive patients with TMB and 134 age- and sex-matched control subjects. All recruited patients received thorough examinations to screen for possible underlying causes.

RESULTS

Of the 134 patients with TMB, 48 patients had ipsilateral carotid arterial lesion and 7 patients had TMB attack(s) caused by cardiac embolism. Of the remaining 79 patients with undetermined cause, 46 had 3 or more TMB attacks (undetermined-frequent group) and 33 had fewer than 3 attacks. In comparison with the control subjects, the TMB patients had greater frequencies of jugular venous reflux (57 vs 30%; p < 0.0001; odds ratio [OR]: 3.079, 95% confidence intervals [CI]: 1.861-5.096) and flow reversal in the superior ophthalmic vein (RSOV; 37 vs 9%; p < 0.0001; OR: 6.052, CI: 3.040-12.048). The undetermined-frequent group had the greatest frequencies of jugular venous reflux (74%, 34 patients; OR: 6.66, CI: 3.13-14.17) and RSOV (59%, 27 patients; OR: 6.51, CI: 3.12-13.58). Of the 50 patients with RSOV, 47 (94%) had RSOV on the side of the TMB attacks.

INTERPRETATION

The increased incidences of jugular and orbital venous reflux in TMB patients suggest that disturbance of cerebral and orbital venous circulation is involved in the pathogenesis of TMB, especially among patients with frequent attacks of undetermined cause.

Transient monocular visual loss

PURPOSE

To provide a practical update on the diagnosis and management of transient monocular visual loss (TMVL).

DESIGN

Perspective.

METHODS

Review of the literature.

RESULTS

TMVL is an important clinical symptom. It has numerous causes but most often results from transient retinal ischemia. It may herald permanent visual loss or a devastating stroke, and patients with TMVL should be evaluated urgently. A practical approach to the evaluation of the patient with TMVL must be based on the patient's age and the suspected underlying etiology. In the older patient, tests should be performed to investigate giant cell arteritis, atherosclerotic large vessel disease, and cardiac abnormalities. In the younger patient, TMVL is usually benign and the evaluation should be tailored to the particular clinical setting.

CONCLUSIONS

Specific prevention strategies are tailored to the most likely cause of TMVL and the patient's underlying risk factors. Prevention of a future event should begin in the ophthalmologist's office with education and aggressive treatment of artherosclerotic risk factors.

Retinal, ophthalmic, or ocular migraine

Ocular migraine, an uncommon cause of transient monocular visual loss, is an entity physicians should be able to recognize in order to provide appropriate treatment and to avoid unnecessary testing. The following text provides an overview of ocular migraine, including discussion of accepted terminology, clinical presentation, and pathophysiology. An ocular and systemic differential diagnosis, appropriate evaluation, therapy, and prognosis are also discussed.

Oscillucusis and sudden deafness in a migraine patient

Migraine is a complex disease that includes neurologic, gastrointestinal and autonomic symptoms, although headache is most common feature. In a portion of cases headache is preceded by focal neurologic symptoms termed auras. Auditory symptoms only rarely occur as part of an aura. We describe a patient whose 13-year migraine history that included the abnormal perception an oscillation of the intensity of ambient sounds (oscillucusis). During a migraine attack immediately after oscillucusis, the patient developed acute and permanent sudden deafness. Clinical and neurologic examinations revealed only profound hearing loss in her left ear. Audiometric testing confirmed the sensorineural nature of the hearing loss. The clinical aspects and physiopathology of auditory symptoms in this case and in patients with migraine is reviewed.

Migraine and isolated recurrent vertigo of unknown cause

Chronic recurrent attacks of vertigo, not associated with any auditory or neurological symptoms, are a common reason for referral to our neurotology clinic. Even after an extensive neurotological evaluation, some cases remain undiagnosed. We prospectively evaluated 72 consecutive patients who presented to the clinic with isolated recurrent vertigo of unknown cause. All patients underwent diagnostic evaluation to exclude identifiable causes of isolated recurrent vertigo. We compared the prevalence of migraine, according to the International Headache Society (IHS) criteria, in the isolated recurrent vertigo group, with a sex- and age-matched control group of orthopedic patients. The prevalence of migraine according to IHS criteria was higher in the isolated recurrent vertigo group (61.1%) than in the control group (10%; p < 0.01). Only 16.7% of patients had an abnormal vestibular function test. The most common abnormal finding was a unilateral vestibular weakness to caloric stimulation. Our results suggest that migraine should be considered in the differential diagnosis of isolated recurrent vertigo of unknown cause.

Migraine-associated dizziness: patient characteristics and management options

OBJECTIVE

To determine patient characteristics and effectiveness of therapy for migraine-associated dizziness.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Patients were identified through a code query of billing records for the diagnosis of migraine-associated vertigo or disequilibrium, based on the International Headache Society criteria. There were 81 patients (61 women, 20 men) with an average age of 36.6 years (range, 8-71 yr); all except four patients were evaluated between 1995 and 1999. Follow-up was obtained from chart review. Mean follow-up time was 54.5 weeks, with a range of 4 to 456 weeks.

INTERVENTION

One or more treatment methods, including dietary manipulation, medication (tricyclic antidepressants, beta-blockers or calcium-channel blockers), and neurology consultation, were applied sequentially as necessary.

MAIN OUTCOME MEASURE

Response to therapy was defined as greater than 75% reduction in symptom recurrence rate.

RESULTS

Overall, 72% of patients experienced resolution or dramatic reduction of their attacks of vertigo or disequilibrium. Of the 13 patients treated with the introduction of dietary manipulation alone, 100% received significant relief. Of the 31 patients treated with dietary manipulation and the addition of a medication, 77% of these patients had significant relief. Of the final group of 37 patients treated with another medication or a neurology consultation, 57% received substantial relief. Of the responders, the majority (>95%) experienced an equal reduction in both vertigo or disequilibrium and headache symptoms. Interestingly, 100% of the patients in the migraine without active headache group received substantial relief of their vertigo or disequilibrium symptoms with migraine therapy.

CONCLUSION

We conclude that there is effective therapy for the common problem of migraine-associated dizziness.

Vasospasm, its role in the pathogenesis of diseases with particular reference to the eye

Vasospasm can have many different causes and can occur in a variety of diseases, including infectious, autoimmune, and ophthalmic diseases, as well as in otherwise healthy subjects. We distinguish between the primary vasospastic syndrome and secondary vasospasm. The term "vasospastic syndrome" summarizes the symptoms of patients having such a diathesis as responding with spasm to stimuli like cold or emotional stress. Secondary vasospasm can occur in a number of autoimmune diseases, such as multiple sclerosis, lupus erythematosus, antiphospholipid syndrome, rheumatoid polyarthritis, giant cell arteritis, Behcet's disease, Buerger's disease and preeclampsia, and also in infectious diseases such as AIDS. Other potential causes for vasospasm are hemorrhages, homocysteinemia, head injury, acute intermittent porphyria, sickle cell disease, anorexia nervosa, Susac syndrome, mitochondriopathies, tumors, colitis ulcerosa, Crohn's disease, arteriosclerosis and drugs. Patients with primary vasospastic syndrome tend to suffer from cold hands, low blood pressure, and even migraine and silent myocardial ischemia. Valuable diagnostic tools for vasospastic diathesis are nailfold capillary microscopy and angiography, but probably the best indicator is an increased plasma level of endothelin-1. The eye is frequently involved in the vasospastic syndrome, and ocular manifestations of vasospasm include alteration of conjunctival vessels, corneal edema, retinal arterial and venous occlusions, choroidal ischemia, amaurosis fugax, AION, and glaucoma. Since the clinical impact of vascular dysregulation has only really been appreciated in the last few years, there has been little research in the according therapeutic field. The role of calcium channel blockers, magnesium, endothelin and glutamate antagonists, and gene therapy are discussed.

The association between cigarette smoking and ocular diseases

Tobacco smoke is composed of as many as 4,000 active compounds, most of them toxic on either acute or long-term exposure. Many of them are also poisonous to ocular tissues, affecting the eye mainly through ischemic or oxidative mechanisms. The list of ophthalmologic disorders associated with cigarette smoking continues to grow. Most chronic ocular diseases, with the possible exception of diabetic retinopathy and primary open-angle glaucoma, appear to be associated with smoking. Both cataract development and age-related macular degeneration, the leading causes of severe visual impairment and blindness, are directly accelerated by smoking. Other common ocular disorders, such as retinal ischemia, anterior ischemic optic neuropathy, and Graves ophthalmopathy, are also significantly linked to this harmful habit. Tobacco smoking is the direct cause of tobacco-alcohol amblyopia, a once common but now rare disease characterized by severe visual loss, which is probably a result of toxic optic nerve damage. Cigarette smoking is highly irritating to the conjunctival mucosa, also affecting the eyes of nonsmokers by passive exposure (secondhand smoking). The dangerous effects of smoking are transmitted through the placenta, and offspring of smoking mothers are prone to develop strabismus. Efforts should be directed toward augmenting the campaign against tobacco smoking by adding the increased risk of blindness to the better-known arguments against smoking. We should urge our patients to quit smoking, and we must make them keenly aware of the afflictions that can develop when smoke gets in our eyes.

Medical management of migraine-related dizziness and vertigo

Historically, review of migraine-related vestibular symptoms has focused on the various clinical presentations that occur and the results of diagnostic studies of vestibular function. Treatment of vestibular symptoms related to migraine has been proposed similar to that used for headache control, but few examples of the effectiveness of this therapy have been published. The purpose of this study is to present the various approaches that can be used to manage vestibular symptoms related to migraine, and to evaluate the overall effectiveness of these treatment approaches. This was a retrospective review of 89 patients diagnosed with migraine-related dizziness and vertigo. The character of vestibular symptoms, pattern of cochlear symptoms, results of auditory and vestibular tests, and comorbidity factors are presented. Treatment was individualized according to symptoms and comorbidity factors, and analyzed regarding effectiveness in control of the major vestibular symptoms of episodic vertigo, positional vertigo, and nonvertiginous dizziness. Medical management included dietary changes, medication, physical therapy, lifestyle adaptations, and acupuncture. Complete or substantial control of vestibular symptoms was achieved in 68 (92%) of 74 patients complaining of episodic vertigo; in 56 (89%) of 63 patients with positional vertigo; and 56 (86%) of 65 patients with non-vertiginous dizziness. Similarly, aural fullness was completely resolved or substantially improved in 34 (85%) of 40 patients; ear pain in 10 (63%) of 16 patients; and phonophobia in 17 (89%) of 19 patients. No patient reported worsened symptoms following medical management. The conflicting concept of a central disorder (migraine) as the cause of cochlear and vestibular dysfunction that often has peripheral features is discussed.

Retinocochleocerebral vasculopathy

We report 10 patients with retinocochleocerebral vasculopathy and review the clinical and diagnostic considerations in previously reported patients with this uncommonly recognized disease. The clinical manifestations include acute and subacute multifocal and diffuse encephalopathic symptoms, hearing loss, and visual loss attributable to microangiopathy affecting the arterioles of the brain, retina, and cochlea. Diagnosis is facilitated by demonstration of retinal arteriolar occlusions without uveitis or keratoconjunctivitis, mid- to low-frequency unilateral or bilateral sensorineural hearing loss, and numerous small foci of increased signal in the white and gray matter on T2 weighted brain magnetic resonance imaging. Because many conditions may produce any combination of strokelike cerebral symptoms, encephalopathy, hearing loss, and visual loss, the differential diagnosis for retinocochleocerebral vasculopathy includes connective tissue disease, demyelinating disease, procoagulant state, infection, neoplasm, and more routine mechanisms of cerebral and retinal ischemia. Brain biopsy specimens demonstrate only minimal nonspecific periarteriolar chronic inflammatory cell infiltration with or without microinfarcts. The demonstration of subclinical arteriolar microangiopathy in muscle biopsy specimens, documented in 3 of our patients may assist in making the diagnosis. The clinical course appears to be monophasic. In addition to corticosteroids, treatment options include immunosuppressant agents (cyclophosphamide or azathioprine) aspirin, calcium channel blockers (nimodipine), intravenous immunoglobulin, and plasmapheresis. The etiology of the disease is unknown, but histopathologic and laboratory evidence suggests that an immune-mediated mechanism may be involved.

Amaurosis fugax in the young

A 36-year-old healthy woman developed amaurosis fugax of the right eye lasting 1 minute. Work-up revealed right carotid stenosis thought most compatible with an atherosclerotic plaque. A carotid endarterectomy was performed which corroborated the radiologic diagnosis. An embolic event from ipsilateral carotid artery disease should be considered as a cause of amaurosis fugax even in the young.

Myxomatous embolization resulting in unilateral amaurosis

A patient with sudden, painless monocular blindness is an uncommon emergency department presentation. Despite often futile attempts to treat the blindness, most clinicians search for a source of possible embolization. A patient is presented that developed monocular blindness without a clinically apparent source. Advanced diagnostic imaging showed a previously undetected atrial myxoma. The salient clinical features, diagnostic techniques, and therapeutic interventions for this uncommon cardiac tumor are discussed.

Prognosis after transient ischemic attack and ischemic stroke in young adults

BACKGROUND AND PURPOSE

We undertook this study to describe the risk of stroke recurrence and functional and occupational status in the long-term follow-up of young adults with ischemic strokes and to identify possible predictors for stroke recurrence, disability, and working status.

METHODS

A cohort of 215 patients aged < or = 45 years with ischemic cerebral events (43 transient ischemic attacks, 135 minor strokes, 37 major strokes), evaluated at our institution from May 1985 through March 1992, was followed for a mean of 43.1 months (SD, 39.7 months; range, 1 to 228 months). Information on death and recurrent cerebral vascular events, functional disability (Rankin Scale), retirement, and working status was obtained from direct observation, mail questionnaire, and telephone interviews.

RESULTS

Four patients (2%) with major strokes died acutely. Information on stroke recurrence and disability was available for 184 (87%) of the survivors and on retirement and working status for 140 (67%) of the patients. Two patients died from cancer. Seven transient ischemic attacks and eight strokes (two hemorrhagic) occurred during follow-up. Patients with strokes of unknown cause experienced no recurrent strokes, contrasting with two deaths and eight strokes in those whose stroke cause was identified (difference between proportions: 8%; 95% confidence interval, 3 to 13). Eighty-eight patients had a complete recovery, and only 21 were disabled (Rankin grades 4 or 5). Logistic regression analysis identified the severity of the initial stroke (Rankin grade > 3) as the only significant predictor of disability (odds ratio, 10.7; 95% confidence interval, 3.7 to 30.6). Of the survivors, 73% were working, and only 18% were retired. Disability at follow-up was the best (but nonsignificant) predictor of retirement (odds ratio, 1.6; 95% confidence interval, 0.8 to 3.4).

CONCLUSIONS

Ischemic stroke in young adults has a low acute mortality and few recurrences, more so if the cause is not identified. The majority of patients return to an active professional life. Severity of the initial stroke is the major predictor of independence. The relation between disability and return to work or retirement is less clear.

Idiopathic recurrent branch retinal arterial occlusion. Natural history and laboratory evaluation

PURPOSE

To investigate the long-term visual and systemic prognosis of patients with idiopathic recurrent branch retinal artery occlusions, and to test recent hypotheses regarding possible causes of this syndrome.

METHODS

The authors retrospectively reviewed the medical and photographic records of 16 eligible patients. Each of 15 living patients was interviewed by one of the authors, then underwent follow-up ophthalmic examination, formal visual field testing, and a battery of clinical laboratory tests.

RESULTS

Over a mean follow-up of 9 years, only three eyes (9%) lost visual acuity from foveal ischemia, although nine eyes (28%) had central and/or extensive peripheral visual field loss at final examination. Ocular neovascular complications developed in eight eyes (25%). Eight patients (50%) had associated vestibuloauditory and/or transient sensorimotor symptoms, but serious permanent neurologic deficits or recurrent systemic thromboembolic events did not develop. Although most patients had one or more vaso-occlusive risk factors, extensive laboratory testing failed to define the etiology of the arterial occlusions.

CONCLUSIONS

On long-term follow-up, the visual, neurologic, and systemic prognosis for most patients with idiopathic recurrent branch retinal arterial occlusions remains favorable. Although it is probable that such patients are etiologically heterogeneous, the authors theorize that many have mild or partial manifestations of the microangiopathic syndrome of encephalopathy, hearing loss, and retinal arteriolar occlusions.

Amaurosis fugax in young people

Nine young adults (median age 19.5 years) who suffered from amaurosis fugax (AF) are described. The attacks of AF were short in duration and preceded by premonitory symptoms in five cases and by a migrainous headache in two. In five patients the visual loss progressed in a lacunar pattern unlike the 'curtain' pattern characteristic of AF in older patients. Investigation revealed no evidence of an embolic or atheromatous aetiology. In two cases a minor abnormality was found on echocardiography. We conclude that AF in young adults has a different clinical pattern and may have a different aetiology, possibly migrainous, compared with that seen in older patients. The pattern of visual loss in some of the cases suggests that the choroidal circulation rather than the retinal circulation is primarily affected.

Recurrent attacks of amaurosis fugax treated with calcium channel blocker

Vasospasm may be one of the causes of amaurosis fugax. A patient is reported who daily experienced multiple brief episodes of amaurosis fugax. The absence of physical, laboratory, or radiographic evidence for thromboembolism, hemodynamic compromise, or vasculitis, suggested that the amaurosis might be caused by vasospasm. This hypothesis was supported by cessation of the attacks of amaurosis when the patient was treated with a calcium channel blocker.