Silent Brain Infarctions and Leukoaraiosis in Patients With Retinal Ischemia

Golsari, Amir; Bittersohl, Diana; Cheng, Bastian; Griem, Pia; Beck, Christoph; Hassenstein, Andrea; Nedelmann, Max; Magnus, Tim; Fiehler, Jens; Gerloff, Christian; Thomalla, Götz

doi:10.1161/strokeaha.117.016467

Cited by 40 publications

(40 citation statements)

References 14 publications

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“…In multiple recent studies it was reported that approximately 15% to 25% of patients with acute retinal ischemia have concurrent acute small cerebral infarctions on diffusion weighted imaging-MRI (DWI-MRI) (8,21,37,52,59,61–64), despite the lack of other focal neurologic deficits at the time of presentation to suggest acute cerebral ischemia. Silent infarctions bear a high risk of future stroke; patients with acute silent cerebral infarctions and acute retinal ischemia most often have a major etiology identified, usually requiring urgent treatment to prevent a subsequent stroke (52,61,63,64).…”

Section: Managementmentioning

confidence: 99%

“…Silent infarctions bear a high risk of future stroke; patients with acute silent cerebral infarctions and acute retinal ischemia most often have a major etiology identified, usually requiring urgent treatment to prevent a subsequent stroke (52,61,63,64). Therefore, all patients with acute retinal ischemia, even in the absence of other focal neurologic deficits, should have an immediate DWI-MRI of the brain to assess for concurrent cerebral ischemia.…”

Section: Managementmentioning

confidence: 99%

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Acute retinal arterial ischemia

Dattilo¹,

Newman²,

Biousse³

2018

Ann. Eye Sci

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Acute retinal arterial ischemia, which includes transient monocular vision loss (TMVL), branch retinal artery occlusion (BRAO), central retinal artery occlusion (CRAO) and ophthalmic artery occlusion (OAO), is most commonly the consequence of an embolic phenomenon from the ipsilateral carotid artery, heart or aortic arch, leading to partial or complete occlusion of the central retinal artery (CRA) or its branches. Acute retinal arterial ischemia is the ocular equivalent of acute cerebral ischemia and is an ophthalmic and medical emergency. Patients with acute retinal arterial ischemia are at a high risk of having further vascular events, such as subsequent strokes and myocardial infarctions (MIs). Therefore, prompt diagnosis and urgent referral to appropriate specialists and centers is necessary for further work-up (such as brain magnetic resonance imaging with diffusion weighted imaging, vascular imaging, and cardiac monitoring and imaging) and potential treatment of an urgent etiology (e.g., carotid dissection or critical carotid artery stenosis). Since there are no proven, effective treatments to improve visual outcome following permanent retinal arterial ischemia (central or branch retinal artery occlusion), treatment must focus on secondary prevention measures to decrease the likelihood of subsequent ischemic events.

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Section: Managementmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

Acute retinal arterial ischemia

Dattilo¹,

Newman²,

Biousse³

2018

Ann. Eye Sci

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“…Data from previous studies support the use of long‐term monitoring for detection of atrial fibrillation as short‐term ECG monitoring of 1 day to 1 month is less effective 11,12,14 . There are limited data on the association of atrial fibrillation and CRAO 5,15–17 . Previous studies have advocated cardiac monitoring for as little as 24 hours to as long as 1 month post‐CRAO.…”

Section: Discussionmentioning

confidence: 99%

Atrial fibrillation post central retinal artery occlusion: Role of implantable loop recorders

Watson

Wellings

Hingorani

et al. 2020

Pacing Clinical Electrophis

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Objective This study evaluated the risk of subclinical atrial fibrillation (AF) in patients with central retinal artery occlusion (CRAO) compared to those with cryptogenic stroke using implantable loop recorders (ILR). Methods We conducted a retrospective analysis of 273 consecutive patients who had ILRs inserted at our institution for either cryptogenic stroke (n = 227) or CRAO (n = 46). Our primary endpoint was a time to event analysis for the new diagnosis of AF by ILR. Univariable and multivariable Cox proportional hazard models were used to determine the predictors of time‐to‐AF. Results A total of 64 patients were found to have newly diagnosed AF by remote monitoring of the ILR. AF was detected in 57 of 227 (25%) cryptogenic stroke patients by the end of a maximum 5.1 years follow‐up and in seven of 46 (15%) CRAO patients by the end of a maximum 3.6 years follow‐up (P = .215, log‐rank test). The Kaplan‐Meier estimates for freedom from AF was 59.4% for CRAO and 66.6% for cryptogenic stroke (P = NS, log‐rank test). Baseline variables predicting AF included older patients, higher CHADS2VASC score, longer PR interval on initial EKG evaluation, and mitral annular calcification on transthoracic echocardiogram. Conclusions Patients with CRAO are at risk for subclinical AF, similar to those with cryptogenic stroke. Long‐term monitoring to detect AF may lead to changes in pharmacotherapy to reduce the risk for subsequent stroke.

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“…The rate of AF in our cohort, although higher than expected is likely to be an underestimate, as almost 40% of patients did not have prolonged cardiac monitoring. Patients with symptomatic CAS and AF are at the highest risk for recurrent cerebrovascular ischaemia; indeed, recent studies showed that up to 20% of patients with monocular visual loss have concurrent silent cortical infarcts on MRI with patients having symptomatic CAS being at most risk [19, 20]. …”

Section: Discussionmentioning

confidence: 99%

Undertreatment of Vascular Risk Factors in Patients with Monocular Ischaemic Visual Loss

Zarkali¹,

Cheng²,

Dados³

et al. 2018

Cerebrovasc Dis

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Background and Purpose: Ischaemic visual loss is often considered a lower risk factor than other transient ischaemic attacks (TIA). We aimed to determine the recurrence risk, prevalence and management of vascular risk factors in these patients. Methods: The study took place in the University College Hospital London daily TIA clinic, main referral centre for North-Central London and Moorfields Eye Hospital. Consecutive records for patients with transient (< 24 h) or permanent (> 24 h) ischaemic visual loss were reviewed during the period January 2014–October 2016. Patients diagnosed with temporal arteritis were excluded. Results: Of 400 patients, 224 (56%) were male with mean age 64.5 years (SD 15.1); 263 patients (65.8%) presented with transient and 137 patients (34.2%) with permanent ischaemic visual loss; 51.3% had hypertension (HTN), 35.3% hypercholesterolaemia, 14.5% diabetes, 11.8% ischaemic ocular events, 10.0% ischaemic heart disease, 7.3% atrial fibrillation (AF), 6.3% TIA, 5.3% stroke, and 12.3% were smokers. Median vascular risk factors were 2 (range 1–6), but 122 (30.5%) had ≥3. Those with diabetes (p < 0.001), HTN (p = 0.008), previous myocardial infarction (p = 0.005), or ≥3 vascular risk factors (p = 0.012) were more likely to present with permanent visual loss, while patients with history of transient events, TIA (p = 0.002), or ocular (p = 0.002) presented with transient visual loss. Ninety-day recurrence was 10.5%; this was higher in patients with ≥3 risk factors (hazard ratio 1.42, 95% CI 0.95–2.11, p = 0.111). Patients with past TIA were more likely to be on secondary prevention than those with ocular ischaemia; 60.0 vs. 34.1% received antiplatelets and 76.0 vs. 43.9% statins. At presentation, only 55.2% (16 patients) with known AF were anticoagulated, despite all of them having CHADSVASC ≥1. Conclusions: Approximately one-third of patients with ocular ischaemia had ≥3 vascular risk factors with recurrences higher in these patients. Yet only half of those with previous ischaemic ocular events were on antiplatelets or statins. These patients should be investigated and treated as aggressively as other forms of TIA or stroke.

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Silent Brain Infarctions and Leukoaraiosis in Patients With Retinal Ischemia

Abstract: Silent cerebral ischemia is present in about 1 in 7 patients with retinal ischemia. The high rate of symptomatic internal carotid artery stenosis suggests that large artery atherosclerosis plays a major role in the pathogenesis of acute retinal ischemia.

Cited by 40 publications

References 14 publications

Acute retinal arterial ischemia

Acute retinal arterial ischemia

Atrial fibrillation post central retinal artery occlusion: Role of implantable loop recorders

Undertreatment of Vascular Risk Factors in Patients with Monocular Ischaemic Visual Loss

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