Postprandial transient painful amaurosis fugax

Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion

Hemichorea-hemiballism (HCHB) due to transient ischemic attacks (TIAs) is rare. An 83-year-old woman had repeated episodes of right-sided HCHB for 3 months. Magnetic resonance (MR) angiography demonstrated occlusion of the left carotid and middle cerebral arteries and severe stenosis of the innominate artery, and 24-hour ambulatory blood pressure monitoring showed a blood pressure decrease of >20 mmHg after each meal. We speculated that HCHB developed as TIAs due to hemodynamic failure in the left cerebral hemisphere, caused by a combination of severe stenosis of the innominate artery concomitant with occlusion of the left carotid and middle cerebral arteries as well as postprandial hypotension.

Mastication steal: an unusual precipitant of cerebrovascular insufficiency

An 83-year-old man had episodic dizziness, visual disturbance, and facial and extremity weakness associated with eating. Occlusion of the ipsilateral common carotid artery and stenosis or occlusion of the major collateral sources were demonstrated. We believe this anatomic configuration, combined with increases in demand for external carotid artery blood flow necessitated by the act of chewing, resulted in a vascular steal syndrome. An extended carotid endarterectomy was performed, and there were no additional episodes.

Transient visual blurring, retro-orbital pain and repetitive involuntary movements in unilateral carotid artery occlusion

An 83-year-old man presented with episodes of right sided retro-orbital pain, visual disturbance, involuntary jerks of his left arm and less frequently his left leg. The symptoms could be triggered by exercise, heat or cough. EEG recordings revealed no epileptic discharges. Duplex ultrasonography showed an occlusion of the right internal carotid artery. Blood flow velocity in the right middle cerebral artery was reduced and vasomotor reactivity to hypercapnia was absent. Reduction of his antihypertensive medication rendered the patient asymptomatic. The combination of transient visual blurring, retro-orbital pain and contralateral limb shaking can be an unusual manifestation of carotid occlusive disease. In such a case, the symptoms may be managed successfully by the elevation of blood pressure.

Postprandial transient visual loss. A symptom of critical carotid stenosis

PURPOSE

The authors report the association of transient visual loss after eating meals with severe carotid occlusive disease, and propose a hypothesis for its pathophysiology.

METHODS

Description of clinical history and examination, radiologic and other studies in two patients with postprandial transient visual loss, and review of the literature for three related cases.

RESULTS

Two women, 59 and 65 years of age, presented with splotchy visual loss lasting up to more than 1 hour in the left and both eyes, respectively. In both patients, the visual loss was precipitated by eating a meal. Radiologic investigations revealed 90% stenosis of the left internal carotid artery in the first patient and occlusion of the right internal carotid artery and 40% to 70% stenosis of the left internal carotid artery in the second patient.

CONCLUSIONS

Visual loss after eating a meal may result from hypoperfusion of the retinal and choroidal circulations and is suggestive of severe carotid occlusive disease.

Ophthalmologic manifestations of carotid occlusive disease

Amaurosis fugax is perhaps the best known ocular symptom of carotid vascular disease. An understanding of the symptoms and an ability to recognise the characteristic changes of hypotensive retinopathy and the ocular ischaemic syndrome should be familiar to ophthalmologists. In patients with known cerebrovascular disease a careful ophthalmologic examination should be performed to evaluate for the presence of ocular involvement related to emboli and hypoperfusion. Once identified a variety of non-invasive and invasive techniques may be employed to determine the degree of stenosis and an individual treatment plan initiated. Early recognition and treatment of patients with carotid occlusive disease may prevent more serious complications.

Transient monocular blindness

Transient monocular blindness (TMB) or amaurosis fugax is diagnosed when visual disturbance or loss (blindness, dimming, fogging, blurring) affects one eye for seconds or minutes. TMB may occur alone or in combination with transient hemispheric ischaemia (TIA). The cause of TMB is usually an atheromatous plaque at the carotid bifurcation in the neck liberating emboli or causing a temporary reduction in carotid and retinal blood flow. In most patients no embolus or ischaemic change is visible in the fundus. TMB should be investigated and treated in the same way as neurologic TIAs with emphasis on rapid detection of extracranial arterial disease, cardiac abnormalities and haematological disorders.