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Poli S, Grohmann C, Wenzel DA, Poli K, Tünnerhoff J, Nedelmann M, Fiehler J, Burghaus I, Lehmann M, Glauch M, Schadwinkel HM, Kalmbach P, Zeller J, Peters T, Eschenfelder C, Agostini H, Campbell BC, Fischer MD, Sykora M, Mac Grory B, Feltgen N, Kowarik M, Seiffge D, Strbian D, Albrecht M, Alzureiqi MS, Auffarth G, Bäzner H, Behnke S, Berberich A, Bode F, Bohmann FO, Cheng B, Czihal M, Danyel LA, Dimopoulos S, Pinhal Ferreira de Pinho JD, Fries FN, Gamulescu MA, Gekeler F, Gomez-Exposito A, Gumbinger C, Guthoff R, Hattenbach LO, Kellert L, Khoramnia R, Kohnen T, Kürten D, Lackner B, Laible M, Lee JI, Leithner C, Liegl R, Lochner P, Mackert M, Mbroh J, Müller S, Nagel S, Prasuhn M, Purrucker J, Reich A, Mundiyanapurath S, Royl G, Salchow DJ, Schäfer JH, Schlachetzki F, Schmack I, Thomalla G, Tieck Fernandez MP, Wakili P, Walter P, Wolf A, Wolf M, Bartz-Schmidt KU, Schultheiss M, Spitzer MS. Early REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION): Study protocol of a phase III trial. Int J Stroke 2024:17474930241248516. [PMID: 38591748 DOI: 10.1177/17474930241248516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
RATIONALE Meta-analyses of case series of non-arteritic central retinal artery occlusion (CRAO) indicate beneficial effects of intravenous thrombolysis when initiated early after symptom onset. Randomized data are lacking to address this question. AIMS The REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION) investigates intravenous alteplase within 4.5 h of monocular vision loss due to acute CRAO. METHODS This study is the randomized (1:1), double-blind, placebo-controlled, multicenter adaptive phase III trial. STUDY OUTCOMES Primary outcome is functional recovery to normal or mildly impaired vision in the affected eye defined as best-corrected visual acuity of the Logarithm of the Minimum Angle of Resolution of 0.5 or less at 30 days (intention-to-treat analysis). Secondary efficacy outcomes include modified Rankin Score at 90 days and quality of life. Safety outcomes include symptomatic intracranial hemorrhage, major bleeding (International Society on Thrombosis and Haemostasis definition) and mortality. Exploratory analyses of optical coherence tomography/angiography, ultrasound and magnetic resonance imaging (MRI) biomarkers will be conducted. SAMPLE SIZE Using an adaptive design with interim analysis at 120 patients, up to 422 participants (211 per arm) would be needed for 80% power (one-sided alpha = 0.025) to detect a difference of 15%, assuming functional recovery rates of 10% in the placebo arm and 25% in the alteplase arm. DISCUSSION By enrolling patients within 4.5 h of CRAO onset, REVISION uses insights from meta-analyses of CRAO case series and randomized thrombolysis trials in acute ischemic stroke. Increased rates of early reperfusion and good neurological outcomes in stroke may translate to CRAO with its similar pathophysiology. TRIAL REGISTRATION ClinicalTrials.gov: NCT04965038; EU Trial Number: 2023-507388-21-00.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Carsten Grohmann
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel A Wenzel
- Department of Ophthalmology, University of Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Max Nedelmann
- Department of Neurology, Regio Kliniken GmbH, Pinneberg, Germany
| | - Jens Fiehler
- Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Ina Burghaus
- Coordination Centre for Clinical Trials (KKS), Medical Faculty & Heidelberg University Hospital, Germany
| | - Monika Lehmann
- Coordination Centre for Clinical Trials (KKS), Medical Faculty & Heidelberg University Hospital, Germany
| | - Monika Glauch
- Center for Rare Diseases, University of Tübingen, Germany
| | - Hauke M Schadwinkel
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pia Kalmbach
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Julia Zeller
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Tobias Peters
- Department of Ophthalmology, University of Tübingen, Germany
| | | | | | - Bruce Cv Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - M Dominik Fischer
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, UK
- Nuffield Laboratory of Ophthalmology, University of Oxford, UK
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Brian Mac Grory
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Nicolas Feltgen
- Department of Ophthalmology, Universitätsspital Basel, Switzerland
| | - Markus Kowarik
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - David Seiffge
- Department of Neurology, University of Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Mohammad S Alzureiqi
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gerd Auffarth
- Department of Ophthalmology, University of Heidelberg, Germany
| | | | - Stefanie Behnke
- Department of Neurology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | | | - Felix Bode
- Department of Neurology, University Hospital Bonn, Germany
| | - Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Czihal
- Medical Clinic and Policlinic IV, Division of Vascular Medicine, Ludwig Maximilian University (LMU), Munich, Germany
| | - Leon A Danyel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | | | - Fabian N Fries
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | | | | | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | | | - Rainer Guthoff
- Department of Ophthalmology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | | | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Ramin Khoramnia
- Department of Ophthalmology, University of Heidelberg, Germany
| | - Thomas Kohnen
- Department of Ophthalmology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - David Kürten
- Department of Ophthalmology, University Hospital, RWTH Aachen University, Aachen, Germany
| | | | - Mona Laible
- Department of Neurology, University Hospital Ulm, Germany
| | - John-Ih Lee
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Christoph Leithner
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Raffael Liegl
- Department of Ophthalmology, University Hospital Bonn, Germany
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Marc Mackert
- Department of Ophthalmology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Susanne Müller
- Department of Neurology, University Hospital Ulm, Germany
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Germany
| | - Michelle Prasuhn
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Jan Purrucker
- Department of Neurology, University of Heidelberg, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | | | - Georg Royl
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Daniel J Salchow
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan H Schäfer
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | | | - Ingo Schmack
- Department of Ophthalmology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria P Tieck Fernandez
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Philip Wakili
- Department of Ophthalmology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | - Peter Walter
- Department of Ophthalmology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Armin Wolf
- Department of Ophthalmology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | - Marc Wolf
- Department of Neurology, Klinikum Stuttgart, Germany
| | | | - Maximilian Schultheiss
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
- AugenChirurgie München, Eye Clinic Herzog Carl Theodor, Munich, Germany
| | - Martin S Spitzer
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Taroza S, Jatužis D, Matijošaitis V, Raugelė S, Valaikienė J. Central retinal artery occlusion or retinal stroke: a neurosonologist's perspective. Front Neurol 2024; 15:1397751. [PMID: 38915799 PMCID: PMC11194405 DOI: 10.3389/fneur.2024.1397751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/22/2024] [Indexed: 06/26/2024] Open
Abstract
In central retinal artery occlusion (CRAO) or retinal stroke, which is usually a vision-threatening condition, timely diagnosis is imperative to improve the chances of retinal preservation and to establish adequate secondary prevention measures. Even though retinal strokes have been traditionally assigned to the field of ophthalmology, while considering reperfusion therapy as the only way to avoid permanent vision loss, we suggest prompt evaluation of CRAO causes (primarily related to cardiovascular risk factors) performed by a well-organized interdisciplinary team (ophthalmologist and neurologist) in a neurovascular center with stroke expertise. Therefore, the most suitable adjunct method for rapidly diagnosing non-arteritic CRAO could be target transorbital ultrasound, performed by an experienced neurologist/neurosonologist in the stroke unit. Consequently, after an ophthalmological assessment, a final decision on thrombolytic therapy could be made. We accept that further research is obviously needed to determine whether transorbital ultrasound could replace ophthalmological investigation in the case of a suspected acute retinal stroke. We assert that retinal stroke requires interdisciplinary treatment in cooperation with neurologists and ophthalmologists, with an additive value for each to achieve the best results for the patient.
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Affiliation(s)
- Saulius Taroza
- Laboratory of Behavioral Medicine, Neuroscience Institute, Lithuanian University of Health Sciences, Palanga, Lithuania
- Klaipėda University Hospital, Klaipėda, Lithuania
| | - Dalius Jatužis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Vaidas Matijošaitis
- Department of Neurology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Saulius Raugelė
- Klaipėda University Hospital, Klaipėda, Lithuania
- Faculty of Health Sciences, Klaipėda University, Klaipėda, Lithuania
| | - Jurgita Valaikienė
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Day J, Monla-Haidar H, Raman V, Weatherby S. Acute monocular visual loss: time to call the stroke team? Pract Neurol 2024:pn-2023-003998. [PMID: 38777569 DOI: 10.1136/pn-2023-003998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Abstract
A man in his 90s presented with acute monocular loss of vision; the emergency department triage alerted the stroke team. He underwent urgent parallel assessments by the stroke and ophthalmology teams and was diagnosed with central retinal artery occlusion. The ultimate decision was made to manage him conservatively, rather than with intravenous thrombolysis, and his visual function has remained poor. We discuss the current evidence for using intravenous thrombolysis in people with central retinal artery occlusion and use this case to exemplify the practical issues that must be overcome if ongoing randomised clinical trials of central retinal artery occlusion confirm a definite benefit from using intravenous thrombolysis.
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Affiliation(s)
- Jacob Day
- Neurology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Vasant Raman
- Ophthalmology, University Hospitals Plymouth NHS Foundation Trust, Plymouth, UK
| | - Stuart Weatherby
- Neurology, University Hospitals Plymouth NHS Foundation Trust, Plymouth, UK
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Stretz C, Paddock JE, Burton TM, Bakaeva T, Freeman M, Choudhury A, Yaghi S, Furie KL, Schrag M, MacGrory BC. IV Thrombolysis for central retinal artery occlusion - Real-world experience from a comprehensive stroke center. J Stroke Cerebrovasc Dis 2024; 33:107610. [PMID: 38301747 PMCID: PMC11145518 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/22/2023] [Accepted: 01/29/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Central retinal artery occlusion (CRAO) is a stroke of the retina potentially amenable to intravenous thrombolysis (IVT). We aimed to determine feasibility of an emergency treatment protocol and risk profile of IVT for CRAO in a comprehensive stroke center (CSC). METHODS We performed a retrospective, observational cohort study including patients with acute CRAO admitted to a CSC over 4 years. Patients are offered IVT if they present with acute vision loss of ≤ 20/200 in the affected eye, have no other cause of vision loss (incorporating a dilated ophthalmologic exam), and meet criteria akin to acute ischemic stroke. We collected socio-demographic data, triage data, time from onset to presentation, IVT candidacy, and rates of symptomatic intracranial hemorrhage (sICH)- or extracranial hemorrhage. RESULTS 36 patients presented within the study period, mean (standard deviation (SD)) age of 70.7 (10), 52 % female, and median time (Q1, Q3) to ED presentation of 13.5 (4.3, 18.8) h. Patients within 4.5 h from onset presented more commonly directly to our ED (66.6 % vs 37.1 %, p = 0.1). Nine patients (25 %) presented within the 4.5 h window. Of those eligible, 7 (77 %) received IVT. There were no events of intracranial or extracranial hemorrhage. CONCLUSIONS Our study confirmed that IVT for acute CRAO is feasible. We found a high rate of treatment with IVT of those eligible. However, because 75 % of patients presented outside the treatment window, continued educational efforts are needed to improve rapid triage to emergency departments to facilitate evaluation for possible candidacy with IVT.
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Affiliation(s)
- Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States.
| | - John E Paddock
- Department of Ophthalmology, Weill Cornell Medicine, Cornell University, New York, NY, United States; Department of Neurology, Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Tina M Burton
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Tatiana Bakaeva
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States; Division of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Melissa Freeman
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Aparna Choudhury
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Karen L Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Brian C MacGrory
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States; Department of Ophthalmology, Duke University School of Medicine, Durham, NC, United States
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Chirurgi R, Duvvi A, Hussain B, Li L, Singh J, Nigussie AH, Hashmi A, Roffe E, Jauhal S, Fasazadeh M, Kalantari H, Hassen GW. Monocular Painless Vision Loss in the Emergency Department: Multipurpose Utility of Point-of-Care Ultrasound. J Emerg Med 2024; 66:192-196. [PMID: 38278678 DOI: 10.1016/j.jemermed.2023.10.011] [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] [Received: 04/26/2023] [Revised: 09/04/2023] [Accepted: 10/01/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Eye-related symptoms are a common presentation in the emergency department (ED). The cases range from simple viral conjunctivitis to trauma-related eye injuries. One pathological condition that could lead to vision loss is retinal artery occlusion (RAO). Evaluating a patient with an eye symptom requires thorough eye examination and advanced imaging in certain instances. Consultation with an ophthalmologist is also necessary for cases that require treatment recommendations and further testing. In the ED, point-of-care ultrasound (POCUS) is a commonly used diagnostic tool that can be used for ocular examination. CASE REPORT We reported a case of a 60-year-old man who presented with painless partial right-eye vision loss. POCUS showed decreased flow in the right central retinal artery with an area of the pale retina seen on the image from the retinal camera, suggesting a possible branch RAO. Further examination with POCUS showed plaque formation at the carotid bifurcation, a potential cause of the patient's symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians and other providers should be encouraged to use POCUS to diagnose eye symptoms accurately and promptly. Abnormal findings will prompt immediate specialty consult and early appropriate management. Our case and other reported cases highlight POCUS's reliability and rapid diagnostic ability.
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Affiliation(s)
- Roger Chirurgi
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Anisha Duvvi
- Albert Einstein College of Medicine, Bronx, New York
| | - Bisma Hussain
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Lucy Li
- Department of Ophthalmology, New York Medical College, Metropolitan Hospital Center, New York, NY
| | - Jaspreet Singh
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Abaynesh Haftu Nigussie
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Ahmed Hashmi
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Estrella Roffe
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Sonja Jauhal
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Misagh Fasazadeh
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Hossein Kalantari
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Getaw Worku Hassen
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
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Alhayek N, Sobczak JM, Vanood A, O’Carroll CB, Demaerschalk BM, Chen J, Dumitrascu OM. Thrombolytic Therapy for Central Retinal Artery Occlusion in an Academic Multi-Site Stroke Centre. Neuroophthalmology 2024; 48:111-121. [PMID: 38487357 PMCID: PMC10936677 DOI: 10.1080/01658107.2023.2290536] [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: 08/24/2023] [Accepted: 11/20/2023] [Indexed: 03/17/2024] Open
Abstract
Central retinal artery occlusion (CRAO) is a subtype of acute ischaemic stroke leading to severe visual loss. A recent American Heart Association scientific statement proposed time-windows for thrombolysis in CRAO similar to acute ischaemic cerebral strokes. We aimed to review our academic multi-site stroke centre experience with intravenous (IVT) and intra-arterial thrombolysis (IAT) in CRAO between 1997 and 2022. Demographic, clinical characteristics, thrombolysis timeline, concurrent therapies, complications, and 3-month follow-up visual acuity (VA) were collected. The thrombolysed cohort follow-up VA was compared with an age, gender and baseline VA matched cohort of CRAO patients that received conservative therapies. Thrombolytic therapy was administered to 3.55% (n = 20) of CRAO admissions; 13 IVT (mean age 68, 61.5% male, 12 alteplase and 1 tenecteplase, all embolic aetiology, 1 CRAO mimic) and 7 IAT (mean age 55, 85.7% male, 3 post-operative and 3 embolic). Additional conservative CRAO-targeting therapies was received by 60%. The median time from onset of visual loss to IVT was 158 minutes (range 67-260). Improvement by at least two Snellen lines was achieved by 25% with 12.5% improving to 20/100 or better. Intracranial haemorrhage post IVT occurred in 1/13 (7.6%). The median time from onset of visual loss to IAT was 335 minutes. Improvement by at least two Snellen lines was achieved by 42%. No difference in 3-month VA was noted between patients that received thrombolysis, either alone (n = 8) or combined with other therapies, and those that received conservative therapies. Our results suggest that the management of acute CRAO remains heterogeneous. The lack of obvious benefit of thrombolysis in our small series supports the need for randomizsd clinical trials comparing thrombolysis to placebo to guide hyperacute CRAO management.
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Affiliation(s)
- Nour Alhayek
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Jacob M. Sobczak
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Aimen Vanood
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Cumara B. O’Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Bart M. Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota, USA
| | - John Chen
- Department of Ophthalmology and Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Oana M. Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
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7
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Baumgartner P, Kook L, Altersberger VL, Gensicke H, Ardila-Jurado E, Kägi G, Salerno A, Michel P, Gopisingh KM, Nederkoorn PJ, Scheitz JF, Nolte CH, Heldner MR, Arnold M, Cordonnier C, Della Schiava L, Hametner C, Ringleb PA, Leker RR, Jubran H, Luft AR, Engelter ST, Wegener S. Safety and effectiveness of IV Thrombolysis in retinal artery occlusion: A multicenter retrospective cohort study. Eur Stroke J 2023; 8:966-973. [PMID: 37421135 PMCID: PMC10683723 DOI: 10.1177/23969873231185895] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/13/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Retinal artery occlusion (RAO) may lead to irreversible blindness. For acute RAO, intravenous thrombolysis (IVT) can be considered as treatment. However, due to the rarity of RAO, data about IVT safety and effectiveness is limited. METHODS From the multicenter database ThRombolysis for Ischemic Stroke Patients (TRISP), we retrospectively analyzed visual acuity (VA) at baseline and within 3 months in IVT and non-IVT treated RAO patients. Primary outcome was difference of VA between baseline and follow up (∆VA). Secondary outcomes were rates of visual recovery (defined as improvement of VA ⩾ 0.3 logMAR), and safety (symptomatic intracranial hemorrhage (sICH) according to ECASS II criteria, asymptomatic intracranial hemorrhage (ICH) and major extracranial bleeding). Statistical analysis was performed using parametric tests and a linear regression model adjusted for age, sex and baseline VA. RESULTS We screened 200 patients with acute RAO and included 47 IVT and 34 non-IVT patients with complete information about recovery of vision. Visual Acuity at follow up significantly improved compared to baseline in IVT patients (∆VA 0.5 ± 0.8, p < 0.001) and non-IVT patients (∆VA 0.40 ± 1.1, p < 0.05). No significant differences in ∆VA and visual recovery rate were found between groups at follow up. Two asymptomatic ICH (4%) and one (2%) major extracranial bleeding (intraocular bleeding) occurred in the IVT group, while no bleeding events were reported in the non-IVT group. CONCLUSION Our study provides real-life data from the largest cohort of IVT treated RAO patients published so far. While there is no evidence for superiority of IVT compared to conservative treatment, bleeding rates were low. A randomized controlled trial and standardized outcome assessments in RAO patients are justified to assess the net benefit of IVT in RAO.
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Affiliation(s)
- Philipp Baumgartner
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lucas Kook
- Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
- Institute for Data Analysis and Process Design, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | | | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kiran M Gopisingh
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan F Scheitz
- Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Lucie Della Schiava
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | | | - Peter A. Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hamza Jubran
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Andreas R Luft
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Castilla-Guerra L, Gómez-Escobar A, Morillo-Sánchez MJ, Fernandez-Moreno MDC. Utility of ocular ultrasonography in the thrombolytic therapy for acute central retinal artery occlusion. Rev Clin Esp 2023; 223:582-583. [PMID: 37716427 DOI: 10.1016/j.rceng.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Affiliation(s)
- Luis Castilla-Guerra
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Virgen Macarena, Sevilla, Spain; Profesor asociado, Facultad de Medicina, Universidad de Sevilla, Spain.
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9
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Gröschel K, Harrer JU, Schminke U, Stegemann E, Allendörfer J. Ultrasound assessment of brain supplying arteries (transcranial). ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:468-486. [PMID: 37832531 DOI: 10.1055/a-2103-4981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Ultrasonography of intracranial arteries is a non-invasive and highly efficient method for the diagnosis and follow-up of patients with cerebrovascular diseases, also in the bedside setting of the critically ill. For reliable assessment and interpretation of sonographic findings, the technique requires - apart from dedicated anatomic and pathophysiological knowledge of cerebral arteries and their hemodynamics - the comprehension of alternative imaging modalities such as CT or MR angiography. This article reviews the transcranial color-coded duplex sonographic (TCCS) examination technique including the transcranial Doppler sonography (TCD) for a standardized ultrasound assessment of the intracranial arteries and typical pathological cases. As a complementary tool, transorbital ultrasound for the assessment of the optic nerve sheath diameter and adjacent structures is also described in this article.
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Affiliation(s)
- Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Judith U Harrer
- Neurology, Private Practice Villa Pfahler, St. Ingbert, Germany
- Neurology, RWTH University Hospital, Aachen, Germany
| | - Ulf Schminke
- Neurology, University Medicine, Greifswald, Germany
| | - Emilia Stegemann
- Clinic for internal medicine, diabetology and angiology, Agaplesion Diakonie Clinics, Kassel, Germany
- Clinic for Cardiology and Angiology, University Hospital Giessen-Marburg, Marburg, Germany
| | - Jens Allendörfer
- Neurology, Asklepios Neurologic Clinic Bad Salzhausen, Nidda, Germany
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10
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Kang DW, Jung KH, Yang W, Kim HM, Kim Y, Chung M, Ha J, Punsalan MT, Lee EJ, Jeong HY, Kim JM, Ko SB, Lee SH. Presence of Embolic Source and Outcome in Central Retinal Artery Occlusion. Neurology 2023; 101:e1364-e1369. [PMID: 37400246 PMCID: PMC10558162 DOI: 10.1212/wnl.0000000000207445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/07/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVES The etiology of central retinal artery occlusion (CRAO) is unclear in approximately 50% of patients, suggesting pathomechanical heterogeneity; moreover, little is known about outcomes according to etiology. This study investigated whether the presence of an embolic source affects outcome in CRAO. METHODS CRAO patients within 7 days of symptom onset were retrospectively enrolled. Clinical parameters, including initial and 1-month visual acuity, CRAO subtype, and brain images, were reviewed. CRAO etiology was categorized as CRAO with or without an embolic source (CRAO-E+ and CRAO-E-). Visual improvement was defined as a decrease in logarithm of the minimum angle of resolution ≥0.3 at 1 month. RESULTS A total of 114 patients with CRAO were included. Visual improvement was noted in 40.4% of patients. Embolic sources were identified in 55.3% of patients, and visual improvement group rather than no improvement group was more commonly associated with the presence of an embolic source. In multivariable logistic regression analysis, CRAO-E+ independently predicted visual improvement (odds ratio 3.00, 95% CI 1.15-7.81, p = 0.025). DISCUSSION CRAO-E+ was found to be associated with a better outcome. CRAO-E+ may be more prone to recanalization than that CRAO-E-.
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Affiliation(s)
- Dong-Wan Kang
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Keun-Hwa Jung
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea.
| | - Wookjin Yang
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Hyeong Min Kim
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Youngjoon Kim
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Matthew Chung
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Jiyeon Ha
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Monique Therese Punsalan
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Eung-Joon Lee
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea.
| | - Han-Yeong Jeong
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Jeong-Min Kim
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Sang-Bae Ko
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea
| | - Seung-Hoon Lee
- From the Department of Neurology (D.-W.K., K.-H.J., W.Y., Y.K., M.C., J.H., M.T.P., E.-J.L., H.-Y.J., J.-M.K., S.-B.K., S.-H.L.), Seoul National University Hospital & Seoul National University College of Medicine; Headquarters for Public Health Care (D.-W.K.), Seoul National University Bundang Hospital, Seongnam; Department of Ophthalmology (H.M.K.), Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Clinical Neurosciences (M.T.P.), University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines; and Korean Cerebrovascular Research Institute (J.-M.K., S.-H.L.), Seoul, South Korea.
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Liu W, Bai D, Kou L. Progress in central retinal artery occlusion: a narrative review. J Int Med Res 2023; 51:3000605231198388. [PMID: 37712755 PMCID: PMC10504844 DOI: 10.1177/03000605231198388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Central retinal artery occlusion (CRAO) is a catastrophic ophthalmic emergency that severely impairs a patient's visual function, often reducing visual acuity to counting fingers or worse. Progress in CRAO research has provided new information regarding its epidemiological characteristics and led to useful assessments through various ophthalmic examinations. Additional insights about CRAO have been gained through studies of its pathophysiological mechanisms, improving intervention timing and enhancing patient prognosis. Treatment for CRAO has evolved, particularly with assistance from surgical instruments and surgical robots. Although surgical treatment is now possible, this option is not widely recognized by ophthalmologists. Conservative therapies have limited benefits compared with the natural course of disease. Recently, pars plana vitrectomy plus endovascular surgery has received considerable interest among ophthalmologists because of its potential efficacy in the treatment of CRAO. Considering the inconsistencies in rationale and efficacy of CRAO treatment modalities, it is important to distinguish between treatment effects and the natural courses of various CRAO subclasses. This narrative review explores progress in CRAO epidemiology, pathophysiology, ophthalmic examination, and treatment.
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Affiliation(s)
- Weishai Liu
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
| | - Dan Bai
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
| | - Lieling Kou
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
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12
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Webb Z. Intravenous Thrombolysis for Central Retinal Artery Occlusion: A Look at the Literature for the Emergency Medicine Physician. Cureus 2023; 15:e41878. [PMID: 37457612 PMCID: PMC10348395 DOI: 10.7759/cureus.41878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Central retinal artery occlusion (CRAO) is a subtype of ischemic stroke and true ocular emergency presenting with acute, painless, monocular vision loss. Typical findings include poor visual acuity (VA), impaired color vision, relative afferent pupillary defect, and on fundoscopic evaluation, retinal edema, cherry red spot, and occasionally visualization of retinal artery emboli. While there are no proven treatments for CRAO, options include orbital massage, hyperbaric oxygen therapy, and intra-arterial or intravenous thrombolysis (IVT). This study reviews the current literature on the efficacy of IVT for patients affected by acute, symptomatic CRAO and provides an up-to-date, evidence-based background for emergency physicians (EPs) who evaluate and manage these patients.
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Affiliation(s)
- Zachary Webb
- Emergency Medicine, Huntington Hospital, Northwell Health, Huntington, USA
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13
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Conticini E, Falsetti P, Fabiani C, Baldi C, Grazzini S, Tosi GM, Cantarini L, Frediani B. Color Doppler Eye Ultrasonography in giant cell arteritis: differential diagnosis between arteritic and non-arteritic sudden blindness. J Ultrasound 2023; 26:313-320. [PMID: 36550390 PMCID: PMC10063765 DOI: 10.1007/s40477-022-00757-1] [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] [Received: 09/28/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Temporal (TA) and axillary (AXA) arteries Color Doppler Ultrasonography (CDUS) is the most reliable diagnostic technique for the diagnosis of giant cell arteritis (GCA), displaying high sensitivity and specificity. Nevertheless, CDUS is still poorly performed in the common clinical practice, being employed only by rheumatologists with a relevant expertise in this field. Color Doppler Eye Ultrasound (CDEUS) is a procedure variously employed in ophthalmology and preliminary findings have displayed a possible role also in the diagnostic work-up of GCA. Aim of this study was to assess whether CDEUS may play a role in the differential diagnosis between arteritic and non-arteritic blindness. METHODS We prospectively included all patients evaluated since September 2021 to May 2022 by our Ophthalmology Unit for sudden blindness and referred to our Vasculitis Clinic in the suspicion of GCA. All patients underwent complete ophthalmological evaluation, routine blood tests, AxA and TA CDUS and CDEUS. According to the definite diagnosis, patients were divided in the following subgroups: (A) patients suffering from arteritic central retinal artery occlusion (CRAO), (B) patients suffering from non-arteritic CRAO, (C) patients suffering from arteritic anterior ischemic optic neuropathy (AION), (D) patients suffering from non-arteritic AION. RESULTS During the observational period, we included a total of 25 patients suffering from sudden blindness and referred to Vasculitis Clinic for ruling out GCA. Patients belonging to group A showed no flow or reduced flow within the territory of central retinal artery (CRA), no "spot sign" and positive TA CDUS; on the other hand, patients from group B presented normal TA CDUS, no flow or reduced flow within the territory of CRA and the presence of "spot sign". Conversely, no relevant difference was evidenced at CDEUS in patients with and without arteritic AION. CONCLUSION Our preliminary data displayed a good reliability of CDEUS in distinguishing between arteritic and non-arteritic CRAO, while no difference was assessed between arteritic and non-arteritic AION. Since AION represents the most common presentation of cranial GCA, CDEUS does not seem a reliable procedure in the diagnostic work-up of GCA and should be restricted only to the exclusion of thrombo-embolic occlusions within the territory of central retinal artery.
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Affiliation(s)
- Edoardo Conticini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Paolo Falsetti
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Claudia Fabiani
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, University of Siena, Siena, Italy
| | - Caterina Baldi
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Silvia Grazzini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Gian Marco Tosi
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, University of Siena, Siena, Italy
| | - Luca Cantarini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy.
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
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Raber FP, Gmeiner FV, Dreyhaupt J, Wolf A, Ludolph AC, Werner JU, Kassubek J, Althaus K. Thrombolysis in central retinal artery occlusion: a retrospective observational study. J Neurol 2023; 270:891-897. [PMID: 36305969 PMCID: PMC9886599 DOI: 10.1007/s00415-022-11439-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is no evidence-based therapy for non-arteritic central retinal artery occlusion (NA-CRAO). Intravenous thrombolysis (IVT) with alteplase in a time window < 4.5 h may lead to a favorable outcome. Purpose of this study was to investigate the feasibility, efficacy and safety of IVT in patients classified as functionally blind. METHODS We conducted a retrospective observational study of NA-CRAO-patients. All patients underwent an ophthalmological and neurological examination including cerebral magnetic resonance imaging (MRI) for assessment of additional stroke lesions. Patients were treated either conservatively or with IVT within 4.5 h. Visual acuity (VA) was evaluated in logMAR and a categorical analysis was performed. RESULTS Thirty-seven patients were included in the study, 21 patients in the conservative treatment group (CTG) and 16 patients in the IVT group. The median logMAR visual acuity at admission and discharge was similar in both groups. The medium symptom to treatment time in the IVT group was 158.0 min. 3 patients (19%) of the IVT group showed a favorable outcome, all CTG patients remained at the level of functional blindness. No serious adverse events were observed after IVT. MRI showed additional acute stroke in over one-third of the patients (n = 14). CONCLUSIONS Early intravenous thrombolysis therapy according to the current stroke protocol n a time window up to 4.5 h after the onset of symptoms was feasible and might be a potential treatment option for NA-CRAO. Patients with NA-CRAO are at very high risk of ischemic stroke and MRI should be done in all patients for optimized treatment and secondary stroke prevention. A prospective randomized study is required.
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Affiliation(s)
- Florian Philipp Raber
- Department of Ophthalmology, University Hospital Ulm, 89075, Ulm, Germany.,Department of Ophthalmology, ViDia Christliche Kliniken, 76135, Karlsruhe, Germany
| | | | - Jens Dreyhaupt
- Institute for Epidemiology and Medical Biometry, Ulm University, 89075, Ulm, Germany
| | - Armin Wolf
- Department of Ophthalmology, University Hospital Ulm, 89075, Ulm, Germany
| | | | - Jens Ulrich Werner
- Department of Ophthalmology, University Hospital Ulm, 89075, Ulm, Germany
| | - Jan Kassubek
- Department of Neurology, University Hospital Ulm, 89081, Ulm, Germany
| | - Katharina Althaus
- Department of Neurology, University Hospital Ulm, 89081, Ulm, Germany.
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15
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[Cardiovascular risk factors, haemostasis and antithrombotic treatment in retinal vessel occlusion]. DIE OPHTHALMOLOGIE 2022; 119:1129-1139. [PMID: 36344732 DOI: 10.1007/s00347-022-01751-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
Venous and arterial retinal vascular occlusions are age-related disorders, generally associated with classical cardiovascular risk factors, rather than an isolated ocular disease. As affected patients often also have an increased general risk for other vascular diseases, such as ischemic stroke, an interdisciplinary clarification of cardiovascular risk factors and systemic comorbidities is essential for all patients. Extended hemostaseological investigations may be recommended in those patients who do not match the typical risk profile. Patients at a young age by the time of manifestation, without conventional risk factors as well as patients with an increased risk of developing antiphospholipid syndrome may require a selective clinical investigation including testing for thrombophilic risk factors. Recent studies have clearly demonstrated an association between coagulation and lipid metabolism disorders and the development of both retinal vein and artery occlusions in specific subgroups of patients. Therapeutic approaches to treat retinal vascular occlusions or reduce the long-term risk of recurrences with anticoagulant or antiplatelet drugs have not gained widespread acceptance. However, intravenous thrombolysis may be a valuable treatment option for central retinal artery occlusions within a short time to treatment therapeutic window. For defined disorders of the coagulation system, the administration of antithrombotic drugs to reduce the general vascular risk can be a reasonable approach. This article provides an overview of cardiovascular risk factors, the general vascular risk and the current state of knowledge on ophthalmologically relevant disorders of coagulation and lipid metabolism in patients with venous and arterial retinal vascular occlusions.
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16
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Retinal Infarction: A Pilot Study on the Efficacy and Safety of Intravenous Thrombolysis and Underlying Aetiologies. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081279. [PMID: 36013458 PMCID: PMC9409746 DOI: 10.3390/life12081279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/15/2022] [Accepted: 08/17/2022] [Indexed: 01/10/2023]
Abstract
Background: Treatment of non-arteritic central retinal artery occlusion is still inconsistent. Therefore, the current study aimed to evaluate the efficacy of intravenous thrombolysis (IVT) and describe the prevalence of co-occurring ischemic brain lesions in patients with acute visual loss due to ischemia. Methods: We analysed 38 consecutive patients with acute visual loss between January 2015 and June 2020. Patients presenting within 4.5 h of symptom onset without any contraindication were treated with IVT. Patients underwent neurologic and ophthalmologic examination and diagnostic workup for the underlying aetiology. Follow-up was performed after 3 and 12 months. Results: Patients treated with IVT had a significantly better functional outcome at discharge compared to patients treated conservatively. No additional ischemic brain lesions were detected (0 of 38). Three patients had extracranial carotid artery stenosis ≥50%. Atrial fibrillation was present in four patients, three of whom already received oral anticoagulation. In the remaining 31 patients no embolic source was detected. However, the number of plaques were rated mild to moderate. Within three months, one patient developed transient visual loss while another suffered a contralateral transient ischemic attack. Conclusions: IVT may represent a safe and effective treatment option in patients with isolated visual loss due to ischemia. The aetiology was atherosclerotic burden rather than embolism caused by carotid stenosis or atrial fibrillation, bringing the current diagnostic procedure and therapy into question. Randomized trials are necessary to evaluate the efficacy and safety of IV thrombolysis and clarify the aetiology of isolated visual loss due to ischemia.
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Wenzel DA, Poli S, Casagrande M, Druchkiv V, Spitzer MS, Bartz-Schmidt KU, Grohmann C, Schultheiss M. Inner Retinal Layer Hyperreflectivity Is an Early Biomarker for Acute Central Retinal Artery Occlusion. Front Med (Lausanne) 2022; 9:854288. [PMID: 35872772 PMCID: PMC9299355 DOI: 10.3389/fmed.2022.854288] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/20/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose To investigate inner retinal hyperreflectivity on optical coherence tomography (OCT) as a potential biomarker indicating acute central retinal artery occlusion (CRAO). Methods A total of 56 patients at two university hospitals with acute CRAO (symptom onset ≤48 h) were included in this retrospective study. The optical intensity of the inner retinal layers was determined in both eyes and the relationship between symptom onset and inner retinal layer optical intensity in OCT scans compared to the unaffected fellow eye was analyzed. Several differential diagnoses [central retinal vein occlusion, anterior ischemic optic neuropathy, diabetic macular edema, and subretinal fibrosis/disciform scar (Junius-Kuhnt)] served as controls to validate optical intensity-based diagnosis of CRAO. Results CRAO strongly correlated with an increased inner retinal layer hyperreflectivity in this cohort with acute CRAO with a time since symptom onset ranging from 1.1 to 48.0 h. Receiver operating characteristic (ROC) analysis showed an area under the curve of 0.99 to confirm CRAO with a true positive rate of 0.93 and a false positive rate of 0.02. No correlation between optical intensity and time since symptom onset was noticeable. None of the differential diagnoses did show an elevated optical intensity of the inner retinal layers as it was detectable in CRAO. Conclusion OCT-based determination of inner retinal layer hyperreflectivity is a very promising biomarker for a prompt diagnosis of CRAO in an emergency setting. This may be of major interest to speed up the administration of a possible thrombolytic treatment.
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Affiliation(s)
- Daniel A. Wenzel
- University Eye Hospital, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | - Maria Casagrande
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vasyl Druchkiv
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin S. Spitzer
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Carsten Grohmann
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schultheiss
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Maximilian Schultheiss,
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Lecler A, Duron L. Functional Analysis of the Central Retinal Artery Using MRI or US. Radiology 2022; 304:E53. [PMID: 35727157 DOI: 10.1148/radiol.213106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Augustin Lecler
- Department of Neuroradiology, Foundation Adolphe de Rothschild Hospital, Paris, France, 25 rue Manin, 75019 Paris, France
| | - Loïc Duron
- Department of Neuroradiology, Foundation Adolphe de Rothschild Hospital, Paris, France, 25 rue Manin, 75019 Paris, France
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Contribution of Orbital Ultrasound to the Diagnosis of Central Retinal Artery Occlusion. J Clin Med 2022; 11:jcm11061615. [PMID: 35329941 PMCID: PMC8952198 DOI: 10.3390/jcm11061615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/06/2022] [Accepted: 03/14/2022] [Indexed: 01/27/2023] Open
Abstract
We aimed to evaluate the diagnostic value of orbital ultrasound in the etiologic diagnosis of central retinal artery occlusion (CRAO). For this purpose, patients with CRAO evaluated at our center between 2011 and 2021 were reviewed. Demographic variables, vascular risk factors and ultrasound findings were collected. An orbital duplex was performed in all cases and complemented with other diagnostic explorations. We attended 36 cases of CRAO. In all patients, orbital ultrasound confirmed the diagnosis of CRAO: in 75% emboli material (spot sign) was observed in CRA and in 25% flow alteration in CRA without visible embolus. The positive spot sign (PSS) group differed from patients with negative spot sign (NSS) in terms of etiology: 8 PSS cases (29.6%) had a major cardioembolic cause, 4 (14.8%) a large vessel atheromatous disease, 15 (55.6%) an undetermined cause. Some 21 (77.8%) PSS patients had some minor cardioembolic cause, mainly calcifications of the left valves. In the NSS group, 2 (22%) were diagnosed with giant cell arteritis (GCA). In CRAO, the ultrasound spot sign could be a guide for the detection of embolic sources. Its absence makes it necessary to consider more strongly the possibility of arteritis. Furthermore, our findings suggest a key role of calcium embolism in PSS patients.
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Chen C, Madike R, Cugati S. A review of the management of central retinal artery occlusion. Taiwan J Ophthalmol 2022; 12:273-281. [PMID: 36248088 PMCID: PMC9558462 DOI: 10.4103/2211-5056.353126] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/30/2022] [Indexed: 11/04/2022] Open
Abstract
Central retinal artery occlusion (CRAO), the ocular analog of a cerebral stroke, is an ophthalmic emergency. The visual prognosis for overall spontaneous visual recovery in CRAO is low. Furthermore, the risk of future ischemic heart disease and cerebral stroke is increased due to the underlying atherosclerotic risk factors. There is currently no guideline-endorsed treatment for CRAO. This review will describe the anatomy, pathophysiology, epidemiology, and clinical features of CRAO, and investigate the current and future management strategies.
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Janská K, Bodnár R, Janský P, Vosko M. INTRAVENOUS THROMBOLYTIC THERAPY FOR ACUTE NONARTERITIC CENTRAL RETINAL ARTERY OCCLUSION. A REVIEW. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2022; 78:101-109. [PMID: 35760581 DOI: 10.31348/2021/32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke. It is a critical condition that often leads to severe visual loss or blindness and can be a harbinger of further cerebrovascular events. Due to the lack of scientific data, there are no effective evidence-based forms of therapy for this condition. None of the conservative therapies have proven effective. The results of some previously published studies suggest a benefit of intravenous thrombolytic therapy in the same regimen as in the treatment of ischemic stroke. This work aims to present an overview of published clinical studies focused on the use of intravenous thrombolysis for CRAO, evaluate its efficacy and safety, and propose an optimal diagnostic and therapeutic algorithm for acute management of CRAO. Summary statistics of patient data from relevant studies indicate that a significant visual acuity improvement was achieved by a total of 45 % of patients receiving alteplase within 4.5 hours of symptoms onset. The occurrence of adverse events in this time window was not significant. Intravenous thrombolytic therapy in CRAO thus appears to be effective and safe. However, we still lack data from adequate prospective randomized controlled trials to confirm this conclusion. To date, two randomized trials are being conducted. The intravenous thrombolysis administration, patient monitoring, etiologic workup, and setting of effective secondary prevention should be ensured at the centre of highly specialized cerebrovascular care. Urgent transport of the CRAO patient to the nearest centre is essential.
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Hu H, Zhang B, Zhao Y, Zhou H, Chen H, Yan S. Efficacy of Intra-Arterial Thrombolysis for Acute Central Retinal Artery Occlusion: A Meta-Analysis. Eur Neurol 2021; 85:186-194. [PMID: 34847561 DOI: 10.1159/000520443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 10/14/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The best management strategy still remains strong controversy for acute nonarteritic central retinal artery occlusion (CRAO). We thus performed a meta-analysis to determine the efficacy of intra-arterial thrombolysis (IAT) for visual improvement according to different times from symptom onset. METHODS We searched EMBASE, PubMed, and Web of Science for relevant studies assessing efficiency of IAT in patients with CRAO compared with standard therapy. Fixed-effects and random-effects models were performed. RESULTS Five eligible studies including 459 patients with acute CRAO were pooled in the meta-analysis. In all, 219 (47.7%) received IAT, and the mean time from symptom onset to IAT was 13 h. The pooled analysis demonstrates odds ratio (OR) for the procedure of IAT and any visual improvement to be 1.520 (95% confidence intervals [CIs] 1.258-1.837; p < 0.001). Subgroup analyses further indicated that the CRAO patients who received IAT achieved any visual improvement more easily within 6 h from symptom onset (OR = 1.703, 95% CI 1.219-2.381; p = 0.002), but not those beyond 6 h (OR = 1.260, 95% CI 0.973-1.632; p = 0.080). CONCLUSION Our meta-analysis of available published data supports IAT to be an alternative treatment option for CRAO patients within 6 h from symptom onset.
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Affiliation(s)
- Haitao Hu
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Bing Zhang
- Department of Neurology, Huzhou Central Hospital, Hangzhou, China
| | - Yuqi Zhao
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Huan Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Hongfang Chen
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Man with sudden visual loss. Ann Emerg Med 2021; 78:796-799. [PMID: 34802591 DOI: 10.1016/j.annemergmed.2021.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Indexed: 11/21/2022]
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Huang L, Wang Y, Zhang R. Intravenous thrombolysis in patients with central retinal artery occlusion: a systematic review and meta-analysis. J Neurol 2021; 269:1825-1833. [PMID: 34625849 DOI: 10.1007/s00415-021-10838-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the efficacy and safety of intravenous thrombolysis (IVT) with alteplase in patients with central retinal artery occlusion (CRAO). METHODS We searched the database of PubMed and EMBASE for potentially eligible studies that reported IVT in CRAO patients from their dates of inception to May 19, 2021. The rate and odds ratios (OR) of best-corrected visual acuity (BCVA) improvement, mean difference (MD) of BCVA with 95% confidence interval (CI) were pooled with random effects model. RESULTS We included 8 studies enrolling 316 CRAO patients, among them, 157 patients received IVT with alteplase while 159 patients did not. The rate of best BCVA improvement was 47% (95% CI 33-62%) in the CRAO patients treated with IVT, which was higher than that of 12% (95% CI 1-23%) in those without IVT (OR 5.97, 95% CI [2.77-12.86]). In the setting of similar baseline BCVA (MD [logMAR] 0.16, 95% CI [- 0.15 to 0.46]), compared with those who did not receive IVT, the CRAO patients who received IVT had better best BCVA (MD [logMAR] - 0.23, 95% CI [- 0.44 to - 0.02]), but had no significant better final BCVA (MD [logMAR] - 0.10, 95% CI [- 0.32 to 0.12]). Two CRAO patients had complicated symptomatic intracranial hemorrhage after IVT. CONCLUSIONS IVT treatment might be effective and safe for CRAO patients, but ocular-specific complications which were not associated with thrombolysis could affect final visual acuity.
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Affiliation(s)
- Lele Huang
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjingbei Street, Heping District, Shenyang, 110001, People's Republic of China
| | - Yujie Wang
- Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Ruijun Zhang
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjingbei Street, Heping District, Shenyang, 110001, People's Republic of China.
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[Acute diagnostics of central retinal artery occlusion and biomarkers of ischemia : Diagnostics with consequences?]. Ophthalmologe 2021; 118:1099-1106. [PMID: 34535826 DOI: 10.1007/s00347-021-01495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute central retinal artery occlusion (CRAO) represents an ophthalmological emergency with neurological implications, which must be immediately investigated and treated. Intravenous thrombolysis could improve the prognosis only within the first 4.5 h due to limited retinal tolerance to ischemia. Accordingly, ophthalmological acute diagnostics should be reduced to the minimum necessary followed by immediate referral to a clinic with neurovascular expertise. The typical anamnesis is well-suited for triaging and should be carried out ín a standardized way in order to determine the onset of symptoms as exactly as possible. In addition to pathognomic findings in fundoscopy, there are characteristic ischemia-related changes in optical coherence tomography (OCT), which document ischemia in the inner retina and under some circumstances can provide inferences for the onset of ischemia. OBJECTIVE This review article summarizes the acute ophthalmological diagnostic management of acute CRAO with a focus on the typical OCT and transorbital ultrasound (TOUS) findings and discusses their potential use as ischemic biomarkers. CONCLUSION Characteristic biomarkers make OCT an important diagnostic tool in the management of acute CRAO. Additional information can be obtained by TOUS. With an evidence-based treatment established in the future both tools could be used for indications for treatment and for estimating the prognosis.
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Complications of Intra-Arterial tPA for Iatrogenic Branch Retinal Artery Occlusion: A Case Report through Multimodal Imaging and Literature Review. MEDICINA-LITHUANIA 2021; 57:medicina57090963. [PMID: 34577886 PMCID: PMC8464858 DOI: 10.3390/medicina57090963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 11/23/2022]
Abstract
Background and Objectives: To document, through multimodal imaging, the post-procedural clinical course and visual outcome of a patient who received intra-arterial tissue plasminogen activator (tPA) for acute iatrogenic branch retinal artery occlusion (BRAO), and to review the literature and guidelines regarding the use of tPA for retinal arterial occlusions. Methods: A 28-year-old female patient who sustained an iatrogenic BRAO and subsequently received intra-arterial tPA was followed through her post-interventional course of 3 months with serial exams and multimodal imaging, including color fundus photography, visual field testing, spectral domain optical coherence tomography (SD-OCT), and OCT angiography (OCT-A). Results: A patient with history of left internal cerebral artery (ICA) aneurysm and baseline visual acuity (VA) of 20/20 developed an acutely symptomatic BRAO after undergoing a neuroendovascular procedure and was acutely treated with tPA through the left ophthalmic artery. At two weeks follow-up, a central posterior pole hemorrhage was noted although VA was preserved. A superior altitudinal defect was shown on automated perimetry. VA dropped to 20/50 at 7 weeks follow-up and hyperreflective material deep to the attachment between the posterior hyaloid and the internal limiting membrane (ILM) consistent with hemorrhage was noted on SD-OCT. At 11 weeks follow-up, VA returned to 20/20, SD-OCT revealed a membrane bridging the foveal depression, OCT-A showed decreased vascularity in the inferior macula, and the visual field defect was stable by automated perimetry. Conclusions: Intraocular hemorrhage is a possible complication of intra-arterial tPA administration for BRAO, and a careful analysis of risks, benefits, and goals of this procedure must be considered by both provider and patient before such intervention.
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Schultheiss M, Spitzer MS, Hattenbach LO, Poli S. [Update on intravenous lysis treatment : The REVISION trial]. Ophthalmologe 2021; 118:1107-1112. [PMID: 34351478 DOI: 10.1007/s00347-021-01467-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND To date, no evidence-based treatment for acute non-arteritic central retinal artery occlusion (CRAO) exists. Considering the limited ischemia tolerance of the retina and the results of multiple case series, increasing expectations are directed towards an early intravenous thrombolysis within 4.5 h after CRAO onset. OBJECTIVE The current literature regards timely retinal reperfusion as the only potentially beneficial therapeutic option to treat non-arteritic CRAO. Available data on the efficacy and safety of thrombolysis in CRAO are presented and discussed. On the basis of these data, the prospective, randomized, double-blind, placebo-controlled REVISION trial (early REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion) will shortly be initiated in 25 centers across Germany in order to investigate early intravenous thrombolysis in acute CRAO. The main inclusion criteria of the REVISION trial are outlined, which may help ophthalmologists to identify study candidates and facilitate rapid referral to a study center. CONCLUSION The efficacy of intravenous thrombolysis in acute ischemic stroke is critically time dependent. This may also be assumed in acute CRAO; however, definite evidence still needs to be provided. Until then, the motto "time is retina" should be applied and intravenous thrombolysis should be offered to CRAO patients as part of randomized trials (such as REVISION). According to the current literature, other acute treatment approaches (such as paracentesis) are not indicated.
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Affiliation(s)
- Maximilian Schultheiss
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Martin S Spitzer
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland
| | | | - Sven Poli
- Hertie-Institut für klinische Hirnforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
- Neurologie mit Schwerpunkt neurovaskuläre Erkrankungen, Universitätsklinikum Tübingen, Tübingen, Deutschland
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[Nonaretritic central retinal artery occlusion as marker for the generalized vascular risk]. Ophthalmologe 2021; 118:1093-1098. [PMID: 34350493 DOI: 10.1007/s00347-021-01466-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Retinal artery occlusion (RAO) represents a limiting visual perception for affected patients. In all efforts to improve function it must not be forgotten that in the vast majority of cases the cause is one or more severe vascular or cardiac diseases, which can cause RAO just as ischemic stroke and can also be life-threatening. OBJECTIVE The aim of this article is to present the available literature and to explain the importance of an intensive neurological internal medical clarification in RAO patients. CONCLUSION Although cardiovascular diseases are already known in most patients at the onset of an RAO, further risk factors are detected in almost 80% of cases. Therefore, and because of the high risk for recurrent thromboembolism, immediate and standardized neurological internal medical clarification of the cause is urgently recommended after an acute RAO in the context of an inpatient stay.
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Abstract
BACKGROUND Acute nonarteritic central retinal artery occlusion (CRAO) is an eye stroke with poor visual prognosis and no proven effective therapies. Given advances in acute stroke care, thrombolysis in CRAO merits critical re-examination. We review the evidence for intravenous (IV) and intra-arterial (IA) tissue plasminogen activator (tPA) in CRAO management. EVIDENCE ACQUISITION MEDLINE, Scopus, and Cochrane online databases were systematically searched from 1960 to present, for reports of acute IV or IA therapy with alteplase or tenecteplase in nonarteritic CRAO patients. English language case reports, case series, interventional studies, or randomized controlled trials were included. The study type, age and number of subjects, the regimen administered, the time since symptoms' onset, visual outcome, and safety reports were noted. RESULTS Use of IV thrombolysis with alteplase was reported in 7 articles encompassing 111 patients, with 54% of them receiving IV tPA within 4.5 hours of symptom onset, and none developing symptomatic intracranial or ocular hemorrhage. Six studies described IA alteplase administration, with only 18 of a total of 134 patients (13.4%) treated within the first 6 hours after visual loss. The reported adverse events were minimal. Visual outcomes post-IV and IA thrombolysis were heterogeneously reported; however, most studies demonstrated benefit of the respective reperfusion therapies when administered very early. We found no reports of tenecteplase administration in CRAO. CONCLUSIONS In 2020, nonarteritic CRAO patients should theoretically receive the same thrombolytic therapies, in the same time window, as patients with acute cerebral ischemia. Eye stroke and teleeye stroke code encounters must include an expert ophthalmologic evaluation to confirm the correct diagnosis and to evaluate for ocular signs that may help guide IV tPA administration or IA management. Future research should focus on developing feasible retinal penumbra imaging studies that, similar to cerebral tissue viability or perfusion imaging, can be incorporated into the thrombolysis decision-making algorithm.
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Intravenous Recombinant Tissue-Type Plasminogen Activator Thrombolysis for Acute Central Retinal Artery Occlusion. J Craniofac Surg 2021; 32:313-316. [PMID: 33156166 DOI: 10.1097/scs.0000000000007134] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Central retinal artery occlusion (CRAO), an ocular stroke, causes severe and permanent visual impairment. Thrombolytic therapy is currently the main treatment option for CRAO. Intravenous thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) has been extensively applied in the treatment of CRAO with the proven advantages of effectiveness and safety. This meta-analysis aimed to assess the efficacy of intravenous rt-PA thrombolysis for the management of CRAO by evaluating the pooled evidence. METHODS A comprehensive literature search of electronic databases including PubMed, OVID, and Cochrane Library was conducted up to and including March 2019. All studies reporting visual outcomes after CRAO with thrombolytic therapy were collected. Data on visual acuity and adverse events were recorded and assessed in this analysis. Data were inputted into the statistical software of STATA. The studies were weighed by the inverse of the variance and merged in a random-effects model. RESULTS The systematic review process yielded 7 eligible studies including 121 patients with CRAO who received the intravenous rt-PA treatment. Sixty-two patients showed improvement in visual acuity (52.0%; 95% CI, 34.0%-70.0%) following rt-PA intravenous thrombolytic therapy. The observed improvement rate in the intravenous rt-PA treatment group was significantly higher than the conservative treatment group (40.4% vs. 13.0%; OR = 5.16; 95% CI, 1.90-14.05). The incidence rate of complications was relatively low (11 out of the 121 patients). Hemorrhage (9/11) was the major reported complication. Mortality was zero. DISCUSSION This meta-analysis indicated that intravenous rt-PA thrombolysis could be an effective and safe strategy for the management of CRAO. However, a more detailed large-scale clinical trial is warranted to strengthen the evidence-based therapeutic guidance.
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Taylor GM, Evans D, Doggette RP, Wallace RC, Flack AT, Kennedy SK. Painless loss of vision: rapid diagnosis of a central retinal artery occlusion utilizing point-of-care ultrasound. Oxf Med Case Reports 2021; 2021:omab038. [PMID: 34158954 PMCID: PMC8212687 DOI: 10.1093/omcr/omab038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 11/14/2022] Open
Abstract
Point-of-care ultrasound (POCUS) has become an essential part of the evaluation of vision loss among emergency physicians in the emergency department (ED). It is frequently used to evaluate for vitreous hemorrhage, foreign bodies, retinal detachment, optic neuritis and posterior vitreous detachment; however, it can also be used to evaluate for a central retinal artery occlusion (CRAO). A POCUS can reveal a hyperechoic density in the optic nerve sheath just proximal to the retinal surface, and this is referred to as a retrobulbar ‘spot sign’ (RBSS). We present the case of an 88-year-old male that presented to our community ED with a painless loss of vision to his right eye. A POCUS revealed an RBSS of the central retinal artery and he was subsequently diagnosed with a CRAO. At his 1-month follow-up, he has regained light perception and 15% of his vision, however, remains with significant visual impairment.
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Affiliation(s)
- Gregory M Taylor
- Assistant Professor of Clinical Emergency Medicine, Indiana University School of Medicine, IU Health Ball Memorial Hospital, Muncie, IN, USA
| | - Daniel Evans
- Emergency Medicine Physician at Mercy Medical Center, Cedar Rapids, IA, USA
| | - Robert P Doggette
- Assistant Professor of Clinical Emergency Medicine, Indiana University School of Medicine, IU Health Ball Memorial Hospital, Muncie, IN, USA.,Methodist Hospital, Indianapolis, IN, USA
| | - Ryan C Wallace
- Assistant Professor of Clinical Emergency Medicine, Indiana University School of Medicine, IU Health Ball Memorial Hospital, Muncie, IN, USA
| | - Andrew T Flack
- Assistant Professor of Clinical Emergency Medicine, Indiana University School of Medicine, IU Health Ball Memorial Hospital, Muncie, IN, USA
| | - Sarah K Kennedy
- Associate Professor of Clinical Emergency Medicine and faculty for the Emergency Ultrasound Fellowship Program, Indiana University School of Medicine, Methodist Hospital, Indianapolis, IN, USA
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Mac Grory B, Schrag M, Poli S, Boisvert CJ, Spitzer MS, Schultheiss M, Nedelmann M, Yaghi S, Guhwe M, Moore EE, Hewitt HR, Barter KM, Kim T, Chen M, Humayun L, Peng C, Chhatbar PY, Lavin P, Zhang X, Jiang X, Raz E, Saidha S, Yao J, Biousse V, Feng W. Structural and Functional Imaging of the Retina in Central Retinal Artery Occlusion - Current Approaches and Future Directions. J Stroke Cerebrovasc Dis 2021; 30:105828. [PMID: 34010777 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105828] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 01/28/2023] Open
Abstract
Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke which affects the retina. Intravenous thrombolysis is emerging as a compelling therapeutic approach. However, it is not known which patients may benefit from this therapy because there are no imaging modalities that adequately distinguish viable retina from irreversibly infarcted retina. The inner retina receives arterial supply from the central retinal artery and there is robust collateralization between this circulation and the outer retinal circulation, provided by the posterior ciliary circulation. Fundus photography can show canonical changes associated with CRAO including a cherry-red spot, arteriolar boxcarring and retinal pallor. Fluorescein angiography provides 2-dimensional imaging of the retinal circulation and can distinguish a complete from a partial CRAO as well as central versus peripheral retinal non-perfusion. Transorbital ultrasonography may assay flow through the central retinal artery and is useful in the exclusion of other orbital pathology that can mimic CRAO. Optical coherence tomography provides structural information on the different layers of the retina and exploratory work has described its utility in determining the time since onset of ischemia. Two experimental techniques are discussed. 1) Retinal functional imaging permits generation of capillary perfusion maps and can assay retinal oxygenation and blood flow velocity. 2) Photoacoustic imaging combines the principles of optical excitation and ultrasonic detection and - in animal studies - has been used to determine the retinal oxygen metabolic rate. Future techniques to determine retinal viability in clinical practice will require rapid, easily used, and reproducible methods that can be deployed in the emergency setting.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Sven Poli
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany.
| | - Chantal J Boisvert
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Martin S Spitzer
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Max Nedelmann
- Department of Neurology, Sana Regio Klinikum, Pinneberg, Germany.
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mary Guhwe
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Elizabeth E Moore
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Hunter R Hewitt
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Kelsey M Barter
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Taewon Kim
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Maomao Chen
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.
| | - Lucas Humayun
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.
| | - Chang Peng
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, North Carolina, USA.
| | - Pratik Y Chhatbar
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Patrick Lavin
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Department of Ophthalmology & Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Xuxiang Zhang
- Department of Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoning Jiang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, North Carolina, USA.
| | - Eytan Raz
- Department of Radiology, NYU Langone Health, New York City, New York. USA.
| | - Shiv Saidha
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Junjie Yao
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.
| | - Valérie Biousse
- Departments of Ophthalmology and Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.
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Mac Grory B, Schrag M, Biousse V, Furie KL, Gerhard-Herman M, Lavin PJ, Sobrin L, Tjoumakaris SI, Weyand CM, Yaghi S. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e282-e294. [PMID: 33677974 DOI: 10.1161/str.0000000000000366] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke that causes severe visual loss and is a harbinger of further cerebrovascular and cardiovascular events. There is a paucity of scientific information on the appropriate management of CRAO, with most strategies based on observational literature and expert opinion. In this scientific statement, we critically appraise the literature on CRAO and provide a framework within which to consider acute treatment and secondary prevention. METHODS We performed a literature review of randomized controlled clinical trials, prospective and retrospective cohort studies, case-control studies, case reports, clinical guidelines, review articles, basic science articles, and editorials concerning the management of CRAO. We assembled a panel comprising experts in the fields of vascular neurology, neuro-ophthalmology, vitreo-retinal surgery, immunology, endovascular neurosurgery, and cardiology, and document sections were divided among the writing group members. Each member received an assignment to perform a literature review, synthesize the data, and offer considerations for practice. Multiple drafts were circulated among the group until consensus was achieved. RESULTS Acute CRAO is a medical emergency. Systems of care should evolve to prioritize early recognition and triage of CRAO to emergency medical attention. There is considerable variability in management patterns among practitioners, institutions, and subspecialty groups. The current literature suggests that treatment with intravenous tissue plasminogen activator may be effective. Patients should undergo urgent screening and treatment of vascular risk factors. There is a need for high-quality, randomized clinical trials in this field.
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Lottspeich C, Mackert MJ, Köhler A, Bauer A, Hoffmann U, Czihal M. Retrobulbar Spot Sign in Metachronous Bilateral Central Retinal Artery Occlusion of Cardioembolic Origin. J Neuroophthalmol 2021; 41:e105-e106. [PMID: 32282511 DOI: 10.1097/wno.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT A 78-year-old man suffered sudden visual loss of his right eye. Five years earlier, he had experienced vision loss of his left eye due to central retinal artery occlusion (CRAO); back then, the etiology for the CRAO was not established. Current ocular ultrasound depicted a hyperechoic spot within the optic nerve in both eyes. Echocardiography identified a calcified mass adherent to the mitral valve as the embolic source of the CRAO. This case shows the value of ocular B-mode ultrasound in demonstration and proof of the etiology for CRAO.
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Affiliation(s)
- Christian Lottspeich
- Division of Vascular Medicine (CL, AK, UH, MC), Medical Clinic and Policlinic IV, University Hospital, Ludwig-Maximilians-University, Munich, Germany ; Department of Ophthalmology (MJM), University Hospital, Ludwig-Maximilians-University, Munich, Germany ; and Medical Clinic and Policlinic I (AB), University Hospital, Ludwig-Maximilians-University, Munich, Germany
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Czihal M, Lottspeich C, Köhler A, Prearo I, Hoffmann U, Priglinger SG, Mackert MJ. Transocular sonography in acute arterial occlusions of the eye in elderly patients: Diagnostic value of the spot sign. PLoS One 2021; 16:e0247072. [PMID: 33577572 PMCID: PMC7880485 DOI: 10.1371/journal.pone.0247072] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/29/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To characterize the diagnostic yield of the spot sign in the diagnostic workup of acute arterial occlusions of the eye in elderly patients. METHODS Clinical characteristics of consecutive patients aged ≥ 50 years with acute central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO) or anterior ischemic optic neuropathy (AION) were recorded. Videos of transocular sonography were assessed for the presence of the spot sign by two blinded readers. Group comparisons were made between CRAO-patients with and without the spot sign. Two experienced cardiovascular physicians allocated CRAO-cases to a presumed aetiology, without and with knowledge on the presence/absence of the spot sign. RESULTS One-hundred-twenty-three patients were included, 46 of whom suffered from CRAO. A spot sign was seen in 32 of 46 of patients with CRAO and in 7 of 23 patients with BRAO. Interobserver agreement was excellent (Cohen`s kappa 0.98). CRAO-patients with the spot sign significantly more frequently had a medical history of cardiovascular disease (62.8 vs. 21.4%, p = 0.03) and left heart valve pathologies (51.9 vs. 10%, p = 0.03). The spot sign was not found in any of the three patients with CRAO secondary to cranial giant cell arteritis. The assumed CRAO aetiology differed in 37% of cases between two cardiovascular physicians, regardless whether transocular sonography findings were known or not. CONCLUSION The spot sign is a simple sonographic finding with excellent interobserver agreement, which proofs the embolic nature of CRAO, but does not allow exact attribution of the underlying aetiology.
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Affiliation(s)
- Michael Czihal
- Division of Vascular Medicine, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Christian Lottspeich
- Division of Vascular Medicine, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- * E-mail:
| | - Anton Köhler
- Division of Vascular Medicine, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Ilaria Prearo
- Division of Vascular Medicine, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Ulrich Hoffmann
- Division of Vascular Medicine, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | | | - Marc J. Mackert
- Department of Ophthalmology, Klinikum der Universität München, LMU München, Munich, Germany
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The Retrobulbar Spot Sign and Prominent Middle Limiting Membrane as Prognostic Markers in Non-Arteritic Retinal Artery Occlusion. J Clin Med 2021; 10:jcm10020338. [PMID: 33477523 PMCID: PMC7831102 DOI: 10.3390/jcm10020338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
Central retinal artery occlusion (CRAO) is characterized by the sudden, painless loss of vision. Typical sonographic and optic coherence tomography (OCT) findings are a retrobulbar spot sign and prominent middle limiting membrane (p-MLM) sign. It remains uncertain whether the retrobulbar spot sign alone or coinciding with the appearance of p-MLM sign is a prognostic marker for visual acuity and the development of secondary retinal ischemia after CRAO. In our prospective cohort study, we included patients with a non-arteritic central artery occlusion < 4 weeks. We examined the following parameters at prespecified time points: ultrasound examination of orbital cavity, Spectral Domain-OCT examination, visual acuity test, and fundoscopy and ultra-widefield angiography to diagnose retinal vascularization. The presence of p-MLM sign in SD-OCT after CRAO was accompanied by significantly better vision during the first four weeks (2.3 (IQR 0.75) vs. 2.6 (IQR 0.33); p = 0.006). Moreover, the spot sign seems to be a prognostic factor for developing secondary retinal ischemia (8 (100%) vs. 0 (0%); p = 0.036). A retrobulbar spot sign seems to be a negative prognostic factor and is associated with secondary retinal ischemia, whereas a p-MLM sign is a somewhat positive prognostic factor for visual acuity.
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Scott IU, Campochiaro PA, Newman NJ, Biousse V. Retinal vascular occlusions. Lancet 2020; 396:1927-1940. [PMID: 33308475 PMCID: PMC9546635 DOI: 10.1016/s0140-6736(20)31559-2] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/29/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022]
Abstract
Acute retinal vascular occlusions are common causes of visual impairment. Although both retinal artery occlusions and retinal vein occlusions are associated with increased age and cardiovascular risk factors, their pathophysiology, systemic implications, and management differ substantially. Acute management of retinal artery occlusions involves a multidisciplinary approach including neurologists with stroke expertise, whereas treatment of retinal vein occlusions is provided by ophthalmologists. Optimisation of systemic risk factors by patients' primary care providers is an important component of the management of these two disorders.
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Affiliation(s)
- Ingrid U Scott
- Department of Ophthalmology and Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Peter A Campochiaro
- Department of Ophthalmology and Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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Ochakovski GA, Wenzel DA, Spitzer MS, Poli S, Härtig F, Fischer MD, Dimopoulos S, Schultheiss M. Retinal oedema in central retinal artery occlusion develops as a function of time. Acta Ophthalmol 2020; 98:e680-e684. [PMID: 32040258 DOI: 10.1111/aos.14375] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/20/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Time is the key criterion in the management of non-arteritic central retinal artery occlusion (NA-CRAO). However, the precise onset of vision loss is often difficult to determine. This study aimed to evaluate the temporal changes of retinal thickness in acute NA-CRAO and the potential of this parameter to be used as a surrogate marker to estimate the onset of retinal ischaemia. METHODS Optical coherence tomography was used to continuously assess retinal thickness and oedema progression rate in six porcine eyes. Additionally, a retrospective analysis of 12 patients with acute NA-CRAO was performed to determine association strength and progression rate between retinal thickness and onset of ischaemia. All Optical coherence tomography (OCT) scans (pigs and NA-CRAO patients) were performed within an ischaemic time frame of up to 9 hr. RESULTS Retinal oedema progression rate in pigs was 25.32 µm/hr [CI 95%: 24.24-26.40 µm/hr]. Retrospective analysis of the patients revealed a strong correlation between retinal oedema and duration of ischaemia (Spearman's rho = 0.77, p = 0.004) with an estimated progression rate of 10.02 µm/hr [CI 95%: 3.30-16.74 µm/hr]. CONCLUSION Retinal thickness increases with oedema formation, and ischaemia onset is strongly correlated with this structural biomarker in both, pigs and NA-CRAO patients. Prospective clinical trials will have to determine the clinical feasibility of retinal thickness measurements as a biomarker to support clinical management of NA-CRAO.
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Affiliation(s)
- G. Alex Ochakovski
- Centre for Ophthalmology University Eye Hospital University Hospital Tübingen Tübingen Germany
- Institute for Ophthalmic Research Centre for Ophthalmology University Hospital Tübingen Tübingen Germany
| | - Daniel A. Wenzel
- Department of Ophthalmology University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
| | - Martin S. Spitzer
- Centre for Ophthalmology University Eye Hospital University Hospital Tübingen Tübingen Germany
- Department of Ophthalmology University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
| | - Sven Poli
- Department of Neurology & Stroke University Medical Center Tübingen Tübingen Germany
- Hertie Institute for Clinical Brain Research University Hospital Tübingen Tübingen Germany
| | - Florian Härtig
- Department of Neurology & Stroke University Medical Center Tübingen Tübingen Germany
- Hertie Institute for Clinical Brain Research University Hospital Tübingen Tübingen Germany
| | - Manuel Dominik Fischer
- Centre for Ophthalmology University Eye Hospital University Hospital Tübingen Tübingen Germany
- Institute for Ophthalmic Research Centre for Ophthalmology University Hospital Tübingen Tübingen Germany
- STZ eyetrial at the Centre for Ophthalmology University Hospital Tübingen Tübingen Germany
- Nuffield Laboratory of Ophthalmology University of Oxford Oxford UK
| | - Spyridon Dimopoulos
- Centre for Ophthalmology University Eye Hospital University Hospital Tübingen Tübingen Germany
| | - Maximilian Schultheiss
- Department of Ophthalmology University Medical Center Hamburg‐Eppendorf (UKE) Hamburg Germany
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Lottspeich C, Mackert MJ, Hoffmann U, Czihal M. [Diagnostic work-up in central retinal artery occlusion and ischemic optic neuropathy - what is important?]. Dtsch Med Wochenschr 2020; 145:1112-1117. [PMID: 32791545 DOI: 10.1055/a-1010-2039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ischemia of the retina in central retinal artery occlusion (CRAO) and of the optic nerve in ischemic optic neuropathy (ION) are common causes of irreversible vision loss in elderly patients and require a thorough diagnostic work-up. First and foremost, giant cell arteritis should be confirmed or ruled out. The further work-up of non-arteritic CRAO and non-arteritic ION (nAION) aims to determine the cardiovascular risk profile. Patients with nAION should be screened for sleep apnoea. In non-arteritic CRAO, the search for embolic sources is the most important diagnostic task. A "white spot sign" seen on transorbital ultrasound confirms the diagnosis of embolic CRAO and rules out an arteritic etiology of CRAO.
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Affiliation(s)
- Christian Lottspeich
- Medizinische Klinik und Poliklinik IV, Interdisziplinäres Ultraschallzentrum, Klinikum der Ludwigs-Maximilians-Universität, München.,Medizinische Klinik und Poliklinik IV, Sektion Angiologie-Gefäßzentrum, Klinikum der Ludwigs-Maximilians-Universität, München
| | - Marc J Mackert
- Augenklinik der Universität München, Klinikum der Ludwig-Maximilians-Universität, München
| | - Ulrich Hoffmann
- Medizinische Klinik und Poliklinik IV, Sektion Angiologie-Gefäßzentrum, Klinikum der Ludwigs-Maximilians-Universität, München
| | - Michael Czihal
- Medizinische Klinik und Poliklinik IV, Sektion Angiologie-Gefäßzentrum, Klinikum der Ludwigs-Maximilians-Universität, München
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Mac Grory B, Nackenoff A, Poli S, Spitzer MS, Nedelmann M, Guillon B, Preterre C, Chen CS, Lee AW, Yaghi S, Stretz C, Azher I, Paddock J, Bakaeva T, Greer DM, Shulman JG, Kowalski RG, Lavin P, Mistry E, Espaillat K, Furie K, Kirshner H, Schrag M. Intravenous Fibrinolysis for Central Retinal Artery Occlusion: A Cohort Study and Updated Patient-Level Meta-Analysis. Stroke 2020; 51:2018-2025. [PMID: 32568646 DOI: 10.1161/strokeaha.119.028743] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Central retinal artery occlusion results in sudden, painless, usually permanent loss of vision in the affected eye. There is no proven, effective treatment to salvage visual acuity and a clear, unmet need for an effective therapy. In this work, we evaluated the efficacy of intravenous tissue-type plasminogen activator (IV alteplase) in a prospective cohort study and an updated systematic review and meta-analysis. METHODS We enrolled consecutive patients with acute central retinal artery occlusion within 48 hours of symptoms onset and with a visual acuity of <20/200 from January 2009 until May 2019. The primary outcomes were safety and functional visual acuity recovery. We compared rates of visual recovery between those treated with alteplase within 4.5 hours of symptom onset to those who did not receive alteplase (including an analysis restricted to untreated patients presenting within the window for treatment). We incorporated these results into an updated systematic review and patient-level meta-analysis. RESULTS We enrolled 112 patients, of whom 25 (22.3% of the cohort) were treated with IV alteplase. One patient had an asymptomatic intracerebral hemorrhage after IV alteplase treatment. Forty-four percent of alteplase-treated patients had recovery of visual acuity when treated within 4.5 hours versus 13.1% of those not treated with alteplase (P=0.003) and 11.6% of those presenting within 4 hours who did not receive alteplase (P=0.03). Our updated patient-level meta-analysis of 238 patients included 67 patients treated with alteplase within 4.5 hours since time last known well with a recovery rate of 37.3%. This favorably compares with a 17.7% recovery rate in those without treatment. In linear regression, earlier treatment correlated with a higher rate of visual recovery (P=0.01). CONCLUSIONS This study showed that the administration of intravenous alteplase within 4.5 hours of symptom onset is associated with a higher likelihood of a favorable visual outcome for acute central retinal artery occlusion. Our results strongly support proceeding to a randomized, placebo-controlled clinical trial.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Alex Nackenoff
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Sven Poli
- Department of Neurology with Focus on Neurovascular Diseases, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Germany (S.P.)
| | - Martin S Spitzer
- Eye Clinic, University Hospital Hamburg-Eppendorf, Germany (M.S.S.)
| | - Max Nedelmann
- Department of Neurology, Sana Regio Klinikum, Pinneberg, Germany (M.N.)
| | - Benoit Guillon
- Department of Neurology, CHU de Nantes - Laennec Nantes, France (B.G., C.P.)
| | - Cécile Preterre
- Department of Neurology, CHU de Nantes - Laennec Nantes, France (B.G., C.P.)
| | - Celia S Chen
- Department of Ophthalmology, Flinders Medical Center and Flinders University, Adelaide, Australia (C.S.C.)
| | - Andrew W Lee
- Department of Neurology, Flinders University and the Calvary Wakefield Hospital, Adelaide, Australia (A.W.L.)
| | - Shadi Yaghi
- Department of Neurology, New York University School of Medicine (S.Y.)
| | - Christoph Stretz
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Idrees Azher
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - John Paddock
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Tatiana Bakaeva
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI.,Division of Ophthalmology, Department of Surgery (T.B.), Warren Alpert Medical School of Brown University, Providence, RI.,Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston (T.B.)
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, MA (D.M.G., J.G.S.)
| | - Julie G Shulman
- Department of Neurology, Boston University School of Medicine, MA (D.M.G., J.G.S.)
| | | | - Patrick Lavin
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Ophthalmology and Visual Sciences (P.L.), Vanderbilt University School of Medicine, Nashville, TN
| | - Eva Mistry
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Kiersten Espaillat
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Karen Furie
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Howard Kirshner
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Matthew Schrag
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
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Acute phase treatment in central retinal artery occlusion: thrombolysis, hyperbaric oxygen therapy or both? J Thromb Thrombolysis 2020; 50:984-988. [DOI: 10.1007/s11239-020-02072-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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42
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Mac Grory B, Lavin P, Kirshner H, Schrag M. Thrombolytic Therapy for Acute Central Retinal Artery Occlusion. Stroke 2020; 51:687-695. [DOI: 10.1161/strokeaha.119.027478] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Brian Mac Grory
- From the Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island (B.M.G.)
| | - Patrick Lavin
- Department of Ophthalmology and Visual Sciences (P.L.), Vanderbilt University School of Medicine, Nashville, TN
- Department of Neurology (P.L., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Howard Kirshner
- Department of Neurology (P.L., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Matthew Schrag
- Department of Neurology (P.L., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
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Smith AT, Wilbert CD, Ferre RM. Using the Retrobulbar Spot Sign to Assist in Diagnosis and Management of Central Retinal Artery Occlusions. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:197-202. [PMID: 31228289 DOI: 10.1002/jum.15073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/03/2019] [Accepted: 05/27/2019] [Indexed: 06/09/2023]
Abstract
Point-of-care ultrasound has become an integral part of the evaluation of monocular vision loss. Most commonly, it has been used to evaluate retinal detachment, vitreous hemorrhage, and posterior vitreous detachment. Point-of-care ultrasound can also be used to evaluate central retinal arterial occlusion, whereby a retrobulbar spot sign is present. We present a case series of 4 patients presenting with monocular vision loss who were found to have central retinal artery occlusion. We describe what a retrobulbar spot sign is and how its presence or absence can assist in the evaluation and treatment of these patients.
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Affiliation(s)
- Austin T Smith
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher D Wilbert
- Emergency Medicine Program, University of Tennessee Health Science Center, College of Medicine, Nashville, Tennessee, USA
| | - Robinson M Ferre
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abstract
PURPOSE OF REVIEW To review recent advances in the management of acute ocular ischemic events, including: transient monocular vision loss, central and branch retinal artery occlusions, and nonarteritic anterior ischemic optic neuropathy. RECENT FINDINGS Transient monocular vision loss and acute retinal arterial occlusions require immediate diagnosis and management, with recognition of these events as transient ischemic attack or stroke equivalents, respectively. Patients should undergo an immediate stroke workup in a stroke center, similar to patients with acute cerebral ischemia. The treatment of central retinal artery occlusions remains limited despite the growing use of thrombolytic treatments. The indication for these treatments remains under debate. No quality evidence exists to support any therapy, including corticosteroids, in the treatment of nonarteritic anterior ischemic optic neuropathy. The highest priority in management is to rule-out giant cell arteritis. SUMMARY Effective therapies for the treatment of ischemic events of the retina and optic nerve remain elusive. Clinicians should focus on the prompt recognition of these events as ocular emergencies and immediately refer patients with vascular transient visual loss and acute central and branch retinal arterial occlusions to the nearest stroke center.
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Sharma RA, Dattilo M, Newman NJ, Biousse V. Treatment of Nonarteritic Acute Central Retinal Artery Occlusion. Asia Pac J Ophthalmol (Phila) 2018; 7:235-241. [PMID: 29717825 DOI: 10.22608/apo.201871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Central retinal artery occlusion (CRAO) is an event most often caused by an embolus originating in the ipsilateral carotid artery, aortic arch, or heart. CRAO may result from partial or complete occlusion of the central retinal artery (CRA), which acts as the primary blood supply to the inner neurosensory retina, and typically results in profound vision loss and permanent visual disability. No consensus has emerged regarding the optimal treatment of CRAO. All proposed treatments are of questionable efficacy and many have uncertain risk profiles. In certain circumstances, thrombolysis may be attempted as a treatment option; however, the evidence to support broad use of thrombolytics in the treatment of acute CRAO remains elusive. It is known that the risk factors that predispose to other cardiovascular and cerebrovascular events are often present in CRAO. Accordingly, identification of patients at highest risk of stroke and secondary prevention of ischemic events remains the primary focus of management. This review offers a summary of the clinical presentation, diagnosis, and prognosis of CRAO, with an emphasis on treatment options.
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Affiliation(s)
- Rahul A Sharma
- Department of Ophthalmology, The University of Ottawa, Ottawa, ON, Canada
| | - Michael Dattilo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA
| | - Valerie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
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Schultheiss M, Härtig F, Spitzer MS, Feltgen N, Spitzer B, Hüsing J, Rupp A, Ziemann U, Bartz-Schmidt KU, Poli S. Intravenous thrombolysis in acute central retinal artery occlusion - A prospective interventional case series. PLoS One 2018; 13:e0198114. [PMID: 29813111 PMCID: PMC5973600 DOI: 10.1371/journal.pone.0198114] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 05/14/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND No evidence-based therapy exists for non-arteritic central retinal artery occlusion (NA-CRAO). Retinal ischemic tolerance is low; irreversible damage occurs within four hours of experimental NA-CRAO. In previous randomized trials evaluating intra-arterial or intravenous thrombolysis (IVT) in NA-CRAO, only one patient was treated this early. In December 2013, the Departments of Neurology & Stroke and Ophthalmology at University Hospital Tuebingen, Germany, decided to treat patients using IVT within 4.5 hours of NA-CRAO, the therapeutic window established for ischemic stroke. MATERIALS AND METHODS Consecutive NA-CRAO patients with severe visual loss received IVT after exclusion of intracranial hemorrhage. Follow-up was conducted at day 5 (d5) and day 30 (d30). Visual outcomes were compared to the conservative standard treatment (CST) arm of the EAGLE-trial. RESULTS Until August 2016, 20 patients received IVT within 4.5 hours after NA-CRAO with a median onset-to-treatment time of 210 minutes (IQR 120-240). Visual acuity improved from baseline mean logarithm of the minimum angle of resolution 2.46±0.33 (SD) (light perception) to 1.52±1.09 (Snellen equivalent: 6/200) at d5 (p = 0.002) and 1.60±1.08 (Snellen equivalent: 6/240) at d30. Compared to the EAGLE CST-arm, functional recovery to reading ability occurred more frequently after IVT: 6/20 (30%) versus 1/39 (3%) at d5 (p = 0.005) and at d30 5/20 (25%) versus 2/37 (5%) (p = 0.045). Two patients experienced serious adverse events (one angioedema and one bleeding from an abdominal aortic aneurysm) but recovered without sequelae. CONCLUSIONS IVT within 4.5 hours after symptom onset may represent an effective treatment of NA-CRAO. Randomized trials are warranted to evaluate efficacy and safety of early IVT in acute NA-CRAO.
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Affiliation(s)
- Maximilian Schultheiss
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- University Eye Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Florian Härtig
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | - Martin S. Spitzer
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- University Eye Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Nicolas Feltgen
- Department of Ophthalmology, University Medical Center Goettingen, Goettingen, Germany
| | - Bernhard Spitzer
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Johannes Hüsing
- Coordination Center for Clinical Trials, University Hospital Heidelberg, Heidelberg, Germany
| | - André Rupp
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | | | - Sven Poli
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
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Abstract
Retinal artery occlusion leads to profound visual impairment in the affected eye. It is rarely caused by local ophthalmic pathologies. Most patients present with a large number of cardio- and cerebrovascular risk factors. Visual loss is the leading symptom in central retinal artery occlusion (CRAO), whereas a circumscribed visual field defect is claimed in branch retinal artery occlusion (BRAO). Although many attempts have been made to improve the course of the disease, no effective therapy is available. There is some hope that intravenous fibrinolysis could influence the natural course but the therapeutic window is small (ca. 4.5 h), and treatment efficacy is still not proven. It is important for ophthalmologists to guide the patients to a comprehensive and prompt neurological and cardiological diagnostic work-up.
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Préterre C, Godeneche G, Vandamme X, Ronzière T, Lamy M, Breuilly C, Urbanczyk C, Wolff V, Lebranchu P, Sevin-Allouet M, Guillon B. Management of acute central retinal artery occlusion: Intravenous thrombolysis is feasible and safe. Int J Stroke 2017; 12:720-723. [DOI: 10.1177/1747493016687578] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Although acute central retinal artery occlusion is as a stroke in the carotid territory (retinal artery), its management remains controversial. The aim of this study was to assess the feasibility and safety of intravenous thrombolysis delivered within 6 h of central retinal artery occlusion in French stroke units. Methods We performed a retrospective analysis of patients treated with intravenous alteplase (recombinant tissue-plasminogen activator), based on stroke units thrombolysis registers from June 2005 to June 2015, and we selected those who had acute central retinal artery occlusion. The feasibility was assessed by the ratio of patients that had received intravenous alteplase within 6 h after central retinal artery occlusion onset among those who had been admitted to the same hospital for acute central retinal artery occlusion. All adverse events were documented. Results Thirty patients were included. Visual acuity before treatment was limited to “hand motion”, or worse, in 90% of the cases. The mean onset-to-needle time was 273 min. The individuals treated with intravenous alteplase for central retinal artery occlusion represented 10.2% of all of the patients hospitalized for central retinal artery occlusion in 2013 and 2014. We observed one occurrence of major bleeding, a symptomatic intracerebral hemorrhage. Conclusion When applied early on, intravenous thrombolysis appears to be feasible and safe, provided that contraindications are given due consideration. Whether intravenous thrombolysis is more effective than conservative therapy remains to be determined. In order to conduct a well-designed prospective randomized control trial, an organized network should be in place.
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Affiliation(s)
- Cécile Préterre
- Department of Neurology, CHU de Nantes – Laënnec Nantes, France
| | - Gaelle Godeneche
- Department of Neurology, CHG La Rochelle-Ré-Aunis, La Rochelle, France
| | - Xavier Vandamme
- Department of Neurology, CHG La Rochelle-Ré-Aunis, La Rochelle, France
| | | | - Matthias Lamy
- Department of Neurology, CHU de Poitiers, Poitiers, France
| | | | - Cédric Urbanczyk
- Department of Neurology, CHD de Vendée Les Oudairies, La Roche sur Yon, France
| | - Valérie Wolff
- Department of Neurology, CHRU de Strasbourg, Strasbourg, France
| | - Pierre Lebranchu
- Department of Ophthalmology, CHU de Nantes – Hôtel Dieu, Nantes, France
| | | | - Benoit Guillon
- Department of Neurology, CHU de Nantes – Laënnec Nantes, France
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