Related Subjects:
|Acute Stroke Assessment (ROSIER&NIHSS)
|Carotid Endarterectomy
|Carotid Stenting
|Artery-to-artery embolic stroke
About
- Can identify significant carotid disease prior to having a full stroke
- Allows earlier initiation of stroke prevention
Aetiology
- Ophthalmic artery is first intracranial branch of internal carotid artery
- Thromboembolism from carotid or systemic embolic risk or low flow
Risks
- Diabetes, Heart disease
- Smoking, Hypertension, Hyperlipidaemia
- Advanced age, Use of cocaine
Causes
- Embolic Events: Cholesterol emboli from atherosclerotic plaques in the carotid artery or aorta. Cardiogenic emboli from atrial fibrillation or other cardiac sources.
- Vascular Insufficiency: Carotid artery stenosis reducing blood flow to the ophthalmic artery or Ophthalmic artery or retinal artery occlusion.
- Inflammatory Conditions: Giant cell arteritis causing inflammation and narrowing of the temporal arteries and affecting branches of ophthalmic artery
- Other Causes: Hypercoagulable states leading to increased risk of thrombus formation. Vasospasm or transient vasoconstriction.
Clinical
- Sudden onset of painless monocular (one eye) blindness
- Lasts seconds to minutes. Clears within 30 min (usually 1.5 min)
- May be described as curtain coming down
- Often in someone with atherosclerosis
- Look for AF, murmurs, cardiomyopathy, carotid bruit
Investigations
- FBC, U&E, ESR for GCA
- ECG for AF
- USS Doppler/CTA/MRA of carotids
- CT head / MRI to look for other evidence of stroke
- Echocardiogram may be needed
Pathology
- Suspect ipsilateral carotid stenosis
Differential of transient monocular visual loss
- Migraine aura
- Giant cell arteritis
- Hypotension
- Central retinal artery/vein occlusion
- Multiple sclerosis
- Papilloedema
- Sickle cell anaemia
Management
- Risk assess and make diagnosis. Can be difficult. I try to label as Possible, Probable and certain
- Smoking cessation and manage vascular risk factors - HTN, Diabetes, Lipids
- Clopidogrel 75 mg OD and High Dose Atorvastatin
- Discuss Carotid endarterectomy or stenting if significant ipsilateral stenosis > 70% and good operative candidate
- Anticoagulate AF with DOAC or Warfarin
- Corticosteroids if giant cell arteritis is diagnosed
References