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Ramadan SM, Rayessa R, Esisi B. Diagnostic challenges of focal neurological deficits during an acute take-Is this vascular?: Clinical hints, pearls and pitfalls. Clin Med (Lond) 2024; 24:100037. [PMID: 38583805 PMCID: PMC11046228 DOI: 10.1016/j.clinme.2024.100037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Stroke and TIAs are amongst the common neurological presentations encountered by specialists and non-specialist health care providers. Despite the advances of neuroimaging techniques, clinicians are frequently faced with diagnostic challenges on evaluation of patients with suspected stroke. In this review, we discuss the characteristic features of cerebrovascular diseases and how to identify them. We also aim to provide a resource for non-stroke specialist clinicians to help them to correctly identify the symptoms and signs of disorders that may masquerade as stroke such as migraine, seizure, and functional disorder, and at the same time we explore how we can identify strokes that present atypically.
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Affiliation(s)
| | | | - Bernard Esisi
- Hull University Teaching Hospitals NHS Trust, Hull, UK
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2
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Martinez-Viguera A, Xuclà-Ferrarons T, Collet R, Olmedo-Saura G, Martí-Fàbregas J, Izquierdo A, Martínez-Domeño A, Prats-Sánchez L, Guasch-Jiménez M, Guisado-Alonso D, Ramos-Pachón A, Camps-Renom P. Clinical characteristics and outcome of amaurosis fugax due to transient retinal ischemia: Results from a contemporary cohort. J Stroke Cerebrovasc Dis 2023; 32:107335. [PMID: 37748428 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/24/2023] [Accepted: 08/28/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Whether presenting an episode of amaurosis fugax (AFx) increases the risk of ischemic stroke is controversial and there is a lack of consensus in the following management. We aimed to describe the clinical characteristics and prognosis of patients with AFx due to suspected transient retinal ischemia. METHODS Observational, retrospective study of patients admitted in a Comprehensive Stroke Center with diagnosis of AFx due to suspected transient retinal ischemia between 2015 and 2020. Clinical characteristics and diagnostic-therapeutic data were collected, as well as recurrences (new episodes of amaurosis and/or ischemic strokes). Multivariable Cox regression analyses were performed to study factors associated with the risk of recurrence. RESULTS We included 91 patients with a mean age of 67.9±14.8 years, 43(47.3%) were women. After the diagnostic workup 14(15.4%) AFx were attributed to an atherothrombotic etiology, 4(4.4%) cardioembolic source, 10(11%) other determined cause (TOAST-OC) and 63(69,2%) indeterminate etiology. 71(78%) patients started antiplatelet therapy and 2(2.2%) anticoagulant therapy. After a median follow-up of 3.5 years (IQR 1.8-5.2), at least one recurrence was recorded in eight (8.8%) patients (four new AFx and four cerebral infarctions). TOAST-OC (HR=9.66, 95% CI 2.41-38.70; p=0.001) and prior history of ischemic stroke (HR=4.21. 95% CI 1.01-17.66; p=0.049) were both independently associated with the risk of recurrence. CONCLUSIONS In two out of three patients, AFx due to transient retinal ischemia was of undetermined cause. The risk of stroke recurrence after a first episode of AFx in our cohort was 8.8%. Patients with TOAST-OC etiology identified were at highest risk of recurrence.
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Affiliation(s)
- Ana Martinez-Viguera
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Av. Sant Antoni Maria Claret 167, Barcelona 08025, Spain.
| | - Tomàs Xuclà-Ferrarons
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Av. Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Roger Collet
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Av. Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Gonzalo Olmedo-Saura
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Av. Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Artur Izquierdo
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Luis Prats-Sánchez
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Marina Guasch-Jiménez
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Daniel Guisado-Alonso
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Anna Ramos-Pachón
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
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Monera Lucas CE, Escolano Serrano J, Romero Valero D, Castilla Martínez G, Pardo López S, Toledano Martos R. Permanent damage of the inner retinal layers in a patient with migraine: a different case of paracentral acute middle maculopathy. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:709-713. [PMID: 36309339 DOI: 10.1016/j.oftale.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 06/16/2023]
Abstract
We report the case of a 20-year-old patient who presented a paracentral scotoma in her left eye that had not disappeared after a migraine attack two days before. Ocular examination showed two pale paracentral areas suggesting an acute ischemia insult. Several causes of retinal ischemia were ruled out and the patient was diagnosed with secondary retinal vasospasm. One year later, the patient suffers an atrophy of the inner layers of the affected retina and has a paracentral chronic scotoma in her left eye. Retinal vasospasms can result in irreversible lesions and chronic symptoms due to ischemia and cell destruction. This unusual case reports a permanent damage due to retinal vasospasm secondary to migraine attack. The finding of typical lesions and the history of migraine could be compatible with the diagnosis of paracentral acute middle maculopathy (PAMM).
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Affiliation(s)
- C E Monera Lucas
- Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain; Universidad Miguel Hernández, Elche, Alicante, Spain.
| | - J Escolano Serrano
- Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - D Romero Valero
- Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - G Castilla Martínez
- Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - S Pardo López
- Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - R Toledano Martos
- Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain
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Ala‐Kauhaluoma M, Nuotio K, Ijäs P, Koskinen SM, Vikatmaa P, Silvennoinen H, Relander K, Lindsberg PJ, Soinne L, Summanen PA. Ocular signs of carotid stenosis in ipsi- and contralateral eyes before and after carotid endarterectomy: a prospective study. Acta Ophthalmol 2022; 100:e1015-e1023. [PMID: 34633762 DOI: 10.1111/aos.15019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/26/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We describe hypoperfusion-related and embolic ocular signs of carotid stenosis (CS) before and six months after carotid endarterectomy (CEA) in a CS population. METHODS We enrolled prospectively 70 CEA patients (81% male, mean age 69) and 41 non-medicated control subjects (76%, 68), from March 2015 to December 2018, assessing intraocular pressure (IOP), best-corrected visual acuity (BCVA) in logMAR units and performing a bio-microscopy examination. RESULTS Main index symptoms included amaurosis fugax (Afx) (29, 41%) and hemispheric TIA (17, 24%), and 17 (24%) were asymptomatic. Of the 70, 17 patients (24%, 95% CI 16-36) showed ocular signs of CS. Of four embolic (Hollenhorst plaques) findings, one small macular plaque disappeared postoperatively. Four had hypoperfusion, that is ocular ischaemic syndrome (OIS), requiring panretinal photocoagulation: one for multiple mid-peripheral haemorrhages, two for iris neovascularization and one for neovascular glaucoma (NVG); only the NVG proved irreversible. Nine (de novo in three) showed mild OIS, that is only few mid-peripheral haemorrhages, ranging pre- /postoperatively in ipsilateral eyes from one to eleven (median two)/ one to two (median one), and in contralateral eyes from three to nine (median five)/ one to six (median three). Pre- and postoperative median BCVA was 0 or better, and mean IOP was normal, except in the NVG patient. Temporary visual impairment from 0 to 0.3 occurred in one eye soon after CEA due to ocular hyperperfusion causing macular oedema. CONCLUSIONS Ocular signs of CS are common in CEA patients, ranging from few mid-peripheral haemorrhages to irreversible NVG. Clinicians should be aware of these signs in detecting CS.
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Affiliation(s)
- Marianne Ala‐Kauhaluoma
- Department of Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Krista Nuotio
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Petra Ijäs
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Suvi Maaria Koskinen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
- Department of Radiology HUS Diagnostic Center University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Pirkka Vikatmaa
- Department of Vascular surgery University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Heli Silvennoinen
- Department of Radiology HUS Diagnostic Center University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kristiina Relander
- Department of Neuropsychology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Perttu J. Lindsberg
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Lauri Soinne
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Paula A. Summanen
- Department of Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki Finland
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Mbonde AA, O'Carroll CB, Dulamea OA, Anghel D, Chong BW, Dumitrascu OM. Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks. Asia Pac J Ophthalmol (Phila) 2022; 11:168-176. [PMID: 35213421 DOI: 10.1097/apo.0000000000000511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.
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Affiliation(s)
- Amir A Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Cumara B O'Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Octaviana A Dulamea
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Daniela Anghel
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Brian W Chong
- Department of Neuroradiology, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US
| | - Oana M Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
- Department of Ophthalmology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
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Thoveson A, Baig IF, Mortensen PW, Lee AG. Hypnic Amaurosis Fugax. J Neuroophthalmol 2022; 42:e357-e358. [PMID: 35051985 DOI: 10.1097/wno.0000000000001315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alec Thoveson
- Texas A&M College of Medicine (AT), Bryan, Texas; Baylor College of Medicine (IFB), Houston, Texas; and Department of Ophthalmology (PWM, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
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