Embolic cilioretinal artery occlusion due to carotid artery dissection

The Relationship between Ischemic Optic Neuropathy and Internal Carotid Artery Dissection: A Systematic Review

Background: To evaluate and review the current evidence regarding the association between ischemic optic neuropathy (ION) and internal carotid artery dissection (ICAD). Methods: We systematically reviewed studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA), searching three databases (Scopus, Pubmed, and Embase) for relevant articles that clearly described the correlation between ION and ICAD. All studies that examined the association between ICAD and the development of ION were synthesized. Quality assessment using the Newcastle-Ottawa Scale (NOS) and Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports and Case Series were conducted. Results: Our search yielded 198 manuscripts published in the English language. Following study screening, fourteen studies were selected. The number of participants with ION following ICAD ranged from one to four, with sixteen patients experiencing either anterior ION, posterior ION, or a combination of both. The anterior or posterior ischemic optic neuropathy (AION and PION) patients' ages were 48.75 ± 11.75 and 49.62 ± 12.85, respectively. Fourteen out of sixteen patients experienced spontaneous ICAD, whereas the traumatic etiology was ascertained in two patients. Conclusions: Hence, albeit rare, ophthalmologists should consider ICAD a potential cause of ION, especially in young adults with concomitant cephalic pain and vision reduction.

Retinal arterial occlusion with multiple retinal emboli and carotid artery occlusion disease. Haemodynamic changes and pathways of embolism

Objective

To introduce a special subgroup, retinal artery occlusion (RAO) with multiple emboli, which is highly associated with ipsilateral carotid artery occlusion disease (CAOD).

Methods and analysis

This is a cohort study. Cases of RAO with multiple retinal emboli were consecutively enrolled. All patients underwent at least one of the carotid/cerebral evaluations: carotid arteriography, orbital/carotid colour Doppler ultrasonography and CT angiography to demonstrate haemodynamic changes and to discuss possible mechanisms and pathways of the emboli.

Results

Among 208 RAO eyes, 12 eyes (5.7%) in 11 patients had multiple emboli were recruited in this study. Eleven eyes (91.6%) had ipsilateral carotid plaques and atherosclerosis with high-grade stenosis; among them, five were total carotid occlusion. Haemodynamic changes were found in nine patients with RAO (81.8%) with carotid stenosis 60% or greater. Most compensatory intracranial circulations were re-established via the circle of Willi with antegrade ophthalmic flows, but the direction of ophthalmic flow reversed in three eyes indicating the recruitment of external collaterals. Two cases underwent carotid stent successfully.

Conclusion

RAOs with multiple emboli are rare but highly associated with severe CAOD with haemodynamic flow changes, warning critical condition in carotid/cerebral circulations. Either direct embolism from the carotid or cardiac lesions or indirect embolism via the collateral pathways is the mechanism of pathogenesis. Immediate action should start to manage these patients to prevent further deterioration.

Ocular ischaemia due to a spontaneous carotid artery dissection

Internal carotid artery dissection (ICAD) is caused by the disruption of the tunica intima, with the formation of an intramural haematoma that can cause stenosis or occlusion of the artery's lumen, leading to reduced blood flow and secondary thrombus formation. Up to two-thirds of patients with ICAD show ophthalmological symptoms or signs, which are, frequently, the first manifestations of this clinical condition, often preceding for weeks the neurological signs of cerebral infarction. Central retinal artery occlusion (CRAO) is a rare complication of ICAD, secondary either to haemodynamic compromise, with ocular hypoperfusion and reverse flow within the ophthalmic artery, or to thromboembolic events, in rarer cases. We report a case of CRAO secondary to a spontaneous ICAD, in an otherwise healthy middle-aged patient.

A Case of Complete Recovery of Fluctuating Monocular Blindness Following Endovascular Treatment in Internal Carotid Artery Dissection

BACKGROUND

Monocular blindness may appear as the first symptom of internal carotid artery dissection (ICAD). However, there have been no reports that monocular visual loss repeatedly occurs and disappears in response to postural change in ICAD.

METHODS

A 33-year-old woman presented with transient monocular blindness (TMB) following acute-onset headache. TMB repeatedly occurred in response to postural change. Two days later, she experienced transient dysarthria and right hemiparesis in upright position. Pupil size and light reflex were normal, but a relative afferent pupillary defect was positive in the left eye. Diffusion-weighted imaging showed no acute lesion, but perfusion-weighted imaging showed perfusion delay in the left ICA territory. Digital subtraction angiography demonstrated a false lumen and an intraluminal filling defect in proximal segment of the left ICA.

RESULTS

Carotid stenting was performed urgently. After carotid stenting, left relative afferent pupillary defect disappeared and TMB was not provoked anymore by upright posture. At discharge, left visual acuity was completely normalized.

CONCLUSIONS

Because fluctuating visual symptoms in the ICAD may be associated with hemodynamically unstable status, assessment of the perfusion status should be done quickly. Carotid stenting may be helpful to improve the fluctuating visual symptoms and hemodynamically unstable status in selected patient with the ICAD.

Topography of the posterior arteries supplying the eye and relations to the optic nerve

PURPOSE

The aim of the study was to investigate the arterial blood supply of the intraorbital part of the optic nerve.

METHODS

The location, course, length and diameter of the central retinal artery (CRA) and posterior ciliary arteries were studied in 19 adult white male preserved cadavers of between 35 and 75 years of age.

RESULTS

In right eyes, the first branch of the intraorbital part of the ophthalmic artery was the CRA in 26.3% (5/19) and the CRA and medial posterior ciliary artery in 21% (4/19) of eyes. In left eyes, the first branch of the intraorbital part of the ophthalmic artery was the CRA in 47.4% (9/19) and the CRA and medial posterior ciliary artery in 26.3% (5/19) of eyes. The CRA was observed as a single branch in 57.9% and a trunk in 42.1% of right eyes, and as a single branch in 52.6% and a trunk in 47.3% of left eyes. The outer diameter of the CRA measured 0.6 +/- 0.1 mm (min-max 0.5-0.9 mm) in right eyes and 0.6 +/- 0.2 mm (min-max 0.4-0.9 mm) in left eyes. The CRA entered the optic nerve 7.5 +/- 2.2 mm (min-max 5.3-12.5 mm) behind the ocular bulb in right eyes and 7.4 +/- 2.3 mm (min-max 5.3-14.1 mm) behind it in left eyes, at its lower and medial side. The posterior ciliary arteries ran forward, divided into multiple branches and pierced the sclera close to the optic nerve medially, laterally or superiorly. The longitudinal capillaries ran between the optic nerve and the CRA antero-posteriorly, while the transverse capillaries surrounded the optic nerve. Collaterals from both the longitudinal and transverse capillaries joined to form a complicated capillary plexus.

CONCLUSION

This article confirms the well known variability of the arterial circulation of the intraorbital part of the optic nerve. Better understanding of the arterial anatomy of the intraorbital part of the optic nerve should enable appropriate modification of surgical techniques.

Anatomic features of the intracranial and intracanalicular portions of ophthalmic artery: for the surgical procedures

The intracranial and intracanalicular portions of the ophthalmic artery is suspectible to various diseases and injuries; therefore, knowledge of the microanatomy of the complex bony, dural, vascular, and neural relationships of this segment is necessary for proper diagnosis and preservation of the neurovascular structures during subfrontal, pterional and intracanalicular procedures. The artery was studied in 38 human adult cadaver specimens regarding origin, intracranial and intracanalicular portions for surgical approachs. The ophthalmic artery originated from the intradural portion of the internal carotid artery, except in 5% where the ophthalmic artery originated extradurally. The ophthalmic artery originated from medial of superior wall of internal carotid artery in 73.7%, from the central in 21% and the lateral in 5.3% of the specimens. The diameter of the ophthalmic artery at its origin was 2.25+/-0.3 mm on the right and 2.16+/-0.4 mm on the left. The intracranial and intracanalicular course of the artery was divided into short limb, angle "a", long limb, angle "b" and distal part to the apex of the orbit. Awareness of variations in anatomic structures is paramount importance both for diagnosis and treatment of vascular lesions of the brain.

Cilioretinal artery occlusions following embolization of an artery to an intracranial meningioma

PURPOSE

To report a case in which a prophylactic embolization of a feeder artery to an intarcranial meningioma led to an occlusion of a cilioretinal artery.

DESIGN

A case report.

METHODS

A 48-year-old man with an intracranial meningioma presented with ocular pain and visual loss in his right eye following embolization of a feeder artery to the meningioma with polyvinyl alcohol.

RESULTS

Ophthalmoscopy 1 month later showed a cilioretinal artery occlusion which was confirmed by fluorescein angiography. His visual acuity was 0.01 in the right eye. The patient was not treated for his ocular symptoms, and his visual acuity 9 month postoperatively improved slightly to 0.1.

CONCLUSIONS

Our case demonstrated that an occlusion of a retinal artery can be a complication of preoperative embolization of an artery to an intracranial tumor and can lead to severe visual loss.